Chapter 21 Breast PPT first 1/2

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1

linear

perpendicular

divergence

Equipment:

  • A _____ transducer should be used.
  • Produces a rectangular shaped image
  • Allows direct contact scanning _____ to the chest wall
  • Accurate measurements can be recorded by avoiding beam _____ artifact
  • Interventional procedures can be accurately guided with a linear array probe.
2

curvilinear

low

Equipment:

  • A ______ transducer may be used to supplement the sonographic examination if a mass is too large to fit on a linear image
  • Using a ___ frequency linear probe provides a large field of view at the expense of resolution.
3

chest wall

3-6

Depth:

  • Depth should be sufficient to visualize the breast tissue from skin to ___ ___
  • Breast size varies from one patient to the next. Depth should be set according to the size of the breast.
  • Usually __-__ cm is sufficient for imaging all structures.
4

Multiple

Focus:

  • ____ focal zones
  • If a single focus is used, the focus should be set at the depth of the area of interest (such as a mass) or below the mammary layer for general scanning.
5

color; power

Power

cannot

Doppler Roles:

  • Both ____ Doppler and ____ Doppler can be useful in breast imaging
  • ____ Doppler is more sensitive to low velocity flow
  • Doppler ____ distinguish between benign and malignant masses
  • Both benign and malignant masses can exhibit blood flow
6

solid

cystic

increase

Doppler:

  • Solid vs. cystic masses
    • Positive flow within a lesion confirms that it is ____
    • Negative internal flow does not confirm that a lesion is ____
  • Inflammed vs. noninflammed tissue
    • The Doppler signal will _____ due to increased flow in areas of inflammation
7

evident; absent

Doppler:

  • Complex cyst vs. intraductal papilloma
    • Doppler signals may be _____ within a papilloma and ____ in the debris of a complex cyst
8

low

Low

Low

Increased

Optimizing Doppler Imaging:

  • In order to optimize doppler imaging, the sonographer should establish a technique for ___ velocity flow states.
  • This includes:
    • ___ velocity scale
    • ____ filter setting
    • Optimal doppler gain setting
    • ____ PRF for high velocities
9

Acoustic enhancement

Shadowing

Artifacts:

  • Artifacts exist in breast sonography as they do in other areas of the body
  • Some artifacts may be helpful in determining characteristics of the tissues.
    • _____ _____ associated with cystic structures or highly cellular benign lesions
    • _____ associated with a solid/malignant lesion
10

Nipple

Unwanted artifacts:

  • Reverberation
  • ____ shadowing
    • Shadowing may be eliminated in this area by angling the transducer posterior to the nipple or by using the “rolled nipple” technique
      • With this technique you place a large “glob” of gel on the nipple to eliminate shadowing from air around the nipple
11

Subcutaneous

Retromammary

Anatomic Layers:

  • From anterior to posterior, the layers of the breast are:
    • Skin
    • ______/premammary layer
    • Mammary or glandular layer
    • ______ space/fat
    • Muscle layer (pectoralis major and minor)
    • Chest wall (ribs, intercostal muscles)
12

epidermis; dermis

0.5-2

younger; thins

Skin:

  • The skin is composed of the _____ and ____ layers.
  • Normal skin thickness is between __-__ mm
  • The skin is slightly thicker in _____ women and ____ as patients age
13

erectile

nerve

15-20

Nipple:

  • Consists of dense connective tissue and _____ muscle
  • It contains many sensory ____ endings
  • __-__ lactiferous duct openings may be seen (each of these arise from a breast lobe)
14

darker

smooth

thicker

Montgomery

Areola:

  • Circular area of ___ pigmentation seen around the nipple
  • Consists of _____ muscle
  • Slightly ____ than surrounding skin
  • Contains _____ glands seen as small bumps in the areola
15

skin

not

fat

increase

coopers

Retinacula cutis

Subcutaneous/pre-mammary layer:

  • Lies just beneath the ____. Extends to the mammary layer
  • Is ___ seen posterior to the nipple
  • Primarily consists of ____
  • Amount of fat will ____ with age, pregnancy
  • Subcutaneous layer also contains ____ ligaments.
  • ____ _____- small ligaments that stretch between the skin and subcutaneous fascia.
16

superficial

superficial; deep

anterior

Superficial Fasia:

  • The breast tissue is completely contained between the layers of the ____ fascia.
  • At the breast, the superficial fascia divides in to the ____ and ____ layers.
  • The superficial layer is simply known as the superficial fascia.
  • The superficial fascia is contained within the subcutaneous layer ____ to the mammary layer.
17

parenchymal

tail of spence

Mammary Layer:

  • Known as the _____ or glandular layer
  • A portion of the glandular tissue extends beyond the breast into the axilla. This is known as the ___ ___ ____.
18

two

fat

Functional

  • The mammary layer is composed of ___ types of tissue:
    • Interlobular ___ and connective tissue
    • Epithelium
      • _____ tissue
      • Consists of acini, lobules, TDLUs lobes and lactiferous ducts
19

Coopers

Suspensory

skeleton

superficial; deep

Mammary Layer:

  • ____ ligaments
    • _____ ligaments
    • Part of the stroma and supportive tissue of the breast
    • Provides a ‘_____’ for the breast
    • Coopers ligaments run between the _____ and _____ layers of the superficial fascia.
20

smallest

milk

Hundreds

ductule

Acini:

  • Also called acinus or acinar cells
  • The _____ functional unit of the breast
  • These are the glands that produce ____
  • ______ are in each breast
  • Each acini gives rise to a ____ or a terminal duct
21

30

Intralobular

Lobule:

  • Composed of approximately ___ acini cells, intralobular terminal ducts
  • ______ stromal tissue (loose connective tissue)
22

Lobule; intralobular; extralobular

2

ALL

Terminal Duct Lobular Unit: TDLU

  • Made up of
    • _____, _____ terminal ducts, _____ terminal ducts
    • Usually measure __ cm or less
    • NEARLY ___ BREAST PATHOLOGY ORIGINATES IN THE TDLU
23

lobules

15-20

lactiferous

Lobe:

  • Several _____ make up a breast lobe
  • __-__ lobes are located in each breast
  • One _______ duct emerges from each lobe and travels toward the nipple
24

milk; acini

terminal duct

lactiferous sinus

collecting

Lactiferous Ducts:

  • Tubes that Transport ____ from the ____ to the nipple
  • Begin at the ___ _____ which arises from the acini.
  • The ducts enlarge slightly at the areola to form the ____ _____.
  • The _____ duct empties milk from the nipple
25

deep

retromammary

cancer

Deep Fascia:

  • The deep later of the superficial fascia is often referred to as the ____ fascia.
  • It is located within the _____ space posterior to the mammary layer
  • Maintaining integrity of the deep fascia is important in deterring the spread of ____ to the chest wall.
26

posterior; pectoral

fat

increases

chest wall

Retromammary Space:

  • Space between the ____ margin of the mammary layer and the _____ muscles
  • Contains a thin layer of ____
  • Amount of fat _____ with age, pregnancy and obesity
  • This later allows movement of the breast over the ____ ____
27

clavicle; sternum

scapula

retromammary

Muscles:

  • Pectoralis major:
    • Arises from the ____ and costal cartilage of the ____ attaching to the proximal humerus
  • Pectoralis minor:
    • Arises from the 3rd, 4th, and 5th ribs attaching to the _____.
    • The pectoral fascia encloses the chest muscles and may appear deep to the _____ layer
28

posterior

Intercostal

lung

Chest Wall:

  • Ribs are located _____ to the pectoral muscles
  • In small breasted females, it is important not to confuse a rib with a breast mass on a physical or sonographic examination.
  • _____ muscles are located within the rib spaces
  • Deep to the chest wall layer is the ____
29

4th

20

testosterone

dormant

Embryonic Development:

  • The primitive mammary gland begins development during the ___ week of life.
  • The glandular tissue of the breast begins to evolve into epithelial buds that eventually form approximately __ epithelial cords or lobes.
  • At 15 weeks gestation, ____ in the male fetus prevents further breast development.
  • Once the fetus is born, the breast tissue is _____ until puberty
30

enlargement

milk

supernumerary

  • Breast _______ may be seen in newborns due to maternal hormonal influence.
  • The breasts develop along a line extending from the axilla to the inguinal region known as the ____ line.
  • Occasionally accessory or _____(extra) breasts are found along this line
31

Absence

Accessory

Absence

Multiple

Anomalies:

  • Amastia
    • _____ of one or both breasts
  • Polymastia
    • _____ breast or more than two breasts
  • Athelia
    • _____ of the nipple
  • Polythelia
    • _____ nipples
32

Absence

flattening; inversion

Assymetric

Anomalies:

  • Amazia
    • _____ of the breast tissue with development of the nipple
  • Nipple _____ or nipple _____
  • Unilateral early ripening
    • _____ breast growth at puberty
33

thoracic

axillary

mammary

subclavian

Arterial Supply:

  • Two main arteries supply blood to the breast.
    • The lateral _____ artery
      • Arises from the _____ artery
  • Internal ____ artery
    • Arises from the _____ artery.
34

deep

mammary; thoracic; axillary; subclavian

Venous Return:

There are two venous systems that drain the breast tissue

  • Superficial
    • Located just ____ to the superficial fascia
  • Deep
    • Include small branches that drain into the internal ____ vein, lateral _____ vein, ____ vein, ____ vein, and intercostal veins.
35

superficial; deep

blood vessels

Lymphatics

  • The ____ and ____ venous systems communicate within the breast parenchyma.
  • Breast cancer most frequently spreads via ____ _____
  • _____ follow roughly the same route as the veins
36

deep; stroma; lactiferous

Intramammary

Lymphatics:

Lymph flow begins ____ within the breast tissues through lymphatic vessels that originate in the ____ and _____ ducts. (deep system)

_____ lymph nodes are seen throughout the breast parenchymas part of the deep system.

37

areola; periareolar; subdermal

subdermal; breast

Lymphatics:

Flow direction from the deep system is toward the ____ into the ____ plexus and continues into the _____ lymphatic vessels which is the superficial system.

From the ____ vessels, lymph flows outward to the outer lymphatic chains that drain the ____

38

lymphatic

75; axilla

breast cancer

Lymphatics:

  • The outer _____ chains are located in multiple areas surrounding the breast
  • Approximately __% of the lymphatic drainage is to the ____.
  • The axillary lymph node chain becomes very important in predicting the spread of an existing ____ ____
39

6

thoracic

subscapular

axillary

Lymphatics:

The axillary lymph node chain consists of __ groups of nodes (75% of drainage):

  • External mammary group
    • Located along the lateral _____ vessels
  • Scapular group
    • Run with the _____ vessels
  • Axillary group
    • Run with the _____ vessels
40

axillary

subclavian

major; minor

Lymphatics:

  • Central group
    • Run with the _____ vessels
  • Subclavicular group
    • Run with the ____ vessels
  • Interpectoral (rotter’s nodes)
    • Found between the pectoralis ____ and _____ muscles
41

25

mammary

Intercostal

opposite

Supraclavicular

Diaphragmatic

Lymphatics:

  • The remaining ___% of lymphatic drainage for breast tissues includes
    • Internal _____ lymph nodes
    • ____ lymph nodes
    • Flow to the ____ breast
    • _____ lymph nodes
    • _____ lymph nodes
42

reniform

cortex; hilum

lymph

fatty; thins; prominent

  • Each lymph node is ____ in shape (like a kidney)
  • It has an outer ____ and a medial ____ where a small artery, vein and lymph vessel enter and exit the node.
  • The vessels carry ____ into the node where it is filtered and released.
  • As lymph nodes become more ____(as a patient ages), the cortex ___ and the hilum becomes more _____.
43

Axillary

lateral

posterior

posterior

During surgical lymph node dissections, the _____ lymph nodes are divided into three levels.

  • Level 1
    • Nodes lie ____ to the pectoralis minor muscle
  • Level 2
    • Nodes lie _____ to the pectoralis muscle
  • Level 3
    • Nodes lie posterior_____ to the muscle
44

thoracic

3rd; 4th

thoracic

  • A complicated network of nerves serve the breast tissue, chest muscles and surrounding areas.
  • These include:
    • Long _____ nerve
    • Thoraco-dorsal nerve
    • Toracic intercostal nerves
    • ___ and ___ branches of the cervical plexus
    • Circumflex nerve
    • Subscapular nerves
    • Anterior _____ nerves
45

puberty

ESTROGEN

PROGESTERONE

Physiology:

  • Puberty
    • At ____, breast development occurs due to hormonal stimulation by the ovaries.
    • The amount of growth and volume depend on the individual
  • _____
    • stimulates changes of the stromal tissues, elongation of the mammary ducts, growth of connective tissue, increase in adipose tissue(fat), and increased vascularity
  • ______
    • Stimulates growth of the glandular tissue
46

menstrual

proliferative

secretory

premenstrual

normal

The mature female breast:

  • Sensitive to the _____ cycle
  • Responds to changing hormones each month
    • Early in the ____ phase of the cycle, changes in the epithelium occur.
    • Later, in the ____ phase, the ducts and veins increase in size, the breasts become edematous (swollen) and the epithelium produces secretions.
  • These changes may account for _____ breast discomfort.
  • At the onset of menses, the breast tissues return to ____.
47

increase; epithelium

Acinar

lactiferous

Pregnancy:

  • During pregnancy, there is a lot of change in the breast tissue.
  • The TDLUs ____ in size and _____ begins to swell.
  • ____ cells enlarge in response to hormones.
  • Late in pregnancy, the ______ ducts increase in size.
48

diminish; PROLACTIN

milk

3

Lactation:

  • Shortly after birth, the estrogen and progesterone levels _____ rapidly and _____ dominates.
  • This hormone causes the acinar cells to secrete ____.
  • After the termination of breast feeding, the ducts and lobules will return to their normal size in __ months.