Breast

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created 5 years ago by Annabelle
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updated 5 years ago by Annabelle
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sonography
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1

How many women will develop breast cancer?

1 in 8

2

True or False?

Breast cancer is the leading cause of death in middle aged women

True

3

When should a breast scan be performed?

a mass is located by palpation or mammography

4

What is the primary reason for breast sonography?

differentiate between

simple cysts

complex cysts

solid masses

5

Why is breast sonography at a disadvantage on young women?

less fat and more parenchyma.

6

what type of machines are used on breast exams?

state of art

less than 5 years

7

What type of transducer should be used on breast exams?

7 MHz - 12 MHz linear

8

What should you do if you find a mass larger than the footprint of the transducer?

change to a curvilinear

9

What is said about the sonographer of breast exams?

breast exams are operator dependent and so should be experienced

10

True or False?

Multiple focuses give better resolution.

true

but temporal resolution takes a hit

11

Where is the retromammary layer located?

in the pectoralis muscles

12

Where are the acini cells?

within the lobules

13

What are acini cells?

milk producing cells

14

lobules + lobules + lobules =

lobe

15

where are lymphatic vessels in the breast?

run from the acini cells to the nipple

16

What are ducts made up of?

basement membrane and a ductal epithelium

17

True or False?

Ductal epithelium are contractile.

True

18

Why does dynamic range improve imaging?

by adding more shades of gray and may demonstrate subtle tissue differences

19

Why are neither color or power Doppler reliable in distinguishing benign from malignant lesions?

both may demonstrate internal flow

20

Why is Doppler helpful during a breast exam?

distinguishing

solid vs cystic - flow confirms a solid

inflamed vs noninflamed - increased flow

complex cyst vs intraductal papilloma

21

True or False?

Doppler can positively confirm solid vs cystic lesions

False

flow confirms a solid

flow does NOT confirm cystic

22

Explain the sonographic appearance of cysts.

anechoic and circular

thin walls

through transmission

23

What is the superficial fascia?

triangular bag that contains the contents of the breast

contained within the subcutaneous layer anterior to the mammary layer

24

Breast anterior to posterior

skin

subcutaneous layer

mammary layer

retromammary space

muscle layer

chest wall

25

How thick is the skin on the breast?

.5 - 2 mm

26

How many lactiferous ducts openings in the nipple?

15-20

27

What does the nipple consist of?

nerve endings & lactiferous ducts

28

What is the areola?

area of dark pigmentation

29

What are Montgomery's glands

small bumps

30

What does the subcutaneous layer primarily consist of?

fat

31

True or False?

Breast fat increases with age

True

32

Does the Fat extend behind the nipple?

NO

33

Explain the sonographic appearance of the subcutaneous layer of the breast.

multiple

homegenous

midlevel gray

lobule structures separated by brightly echogenic ligaments

34

Where are the cooper's ligaments?

runs between superficial to deep layers

extends from the clavicle and the pectoralis muscles to the skin

35

What is the sonographic appearance of Cooper's ligaments?

thin brightly echogenic membranes separating fat lobules

36

What is the purpose of Cooper's ligaments?

provide skeletal framework of the breast

37

Why can Cooper's ligaments be a pitfall?

may cause acoustic shadowing

38

What is another name for the Mammary layer?

parenchymal

Glandular layer

39

What is the Tail of Spence?

portion of the glandular tissue that extends into the axilla

40

What does the mammary layer consist of?

stoma

epithelium

41

What is breast stroma?

supportive tissue in the mammary layer

42

What does the stroma consist of?

interlobular fat

loose and dense connective tissue

cooper's ligaments

43

What is Breast Epithelium?

Functional tissue of the breast

44

What does breast epithelium consist of?

acini

terminal Duct Lobular units TDLU

Lobules

Lobes

Lactiferous ducts

45

What are the smallest functional unit in the breast?

acini cells

46

How many acini cells in each breast?

hundreds

47

How many acini cells in each TDLU?

30

48

True or False?

Each acini gives rise to a terminal duct.

true

49

What is the order of the breast?

Acini (30)

TDLU (lots)

Lobules (10-15)

Lobes (15-20)

Breast

50

What is a TDLU

terminal Duct Lobular units

51

What is the usual measurement for the TDLU?

2 mm or less

52

Where does almost all breast pathology originate?

TDLU

53

How many acini and terminal ducts form a lobule?

30

54

How many lobules make up a lobe

10-15

55

How many lobes in a breast?

15 to 20

56

What emerges from each from lobe and travels toward the nipple?

lactiferous duct

57

What carries milk?

lactiferous duct

acini to nipple

58

What are the lactiferous ducts called arising from the acini?

terminal ducts

59

What are the lactiferous ducts called in the lobules?

intralobular

60

What are the lactiferous ducts called in the lobes?

extralobular

61

What are the lactiferous ducts beneath the areola?

lactiferous sinus

62

What are the two muscles of the breast?

pectoralis major

pectoralis minor

63

Where does the pectoralis minor arise?

3rd, 4th and 5th ribs

64

Where does the pectoralis major arise?

clavicle and costal cartilage of the sternum

65

Which muscle is anterior?

pectoralis major

66

What causes breast development?

hormonal stimulation by the ovaries

67

What does Estrogen stimulate in the breast?

elongation

increase in connective tissue

adipose tissue

vascularity

68

What does progesterone stimulate in the breast?

growth of TDLU

69

What are the menstrual Breast changes during days 1-5?

decrease in size

70

What are the menstrual Breast changes during days 6-9?

Menstrual post

71

What are the menstrual Breast changes during days 6-13?

proliferated or production of acini cells TDLU

72

What are the menstrual Breast changes during days 13-28?

Secretory - ducts enlarge edematous

73

What happens to the breast in the early stage of pregnancy?

lactiferous ducts increase in size

74

What happens to the breast in the late stage of pregnancy?

stroma is crowded and displaced

75

What stimulates the production of milk?

prolactin dominates after birth and acini cells secrete milk

76

When do ducts and lobules return to their normal size after pregnancy?

3 months after termination of breast feeding

77

What happens to the breast during menopause?

Shrivel and roll forward

loose - dense

dense - stoma

strom - fat

78

What two main arteries supply the breast?

Lateral Thoracic

Internal Mammary

79

Where does the Lateral Thoracic Artery arise from?

the axillary artery

80

Where does the Internal Mammary Artery arise from?

subclavian artery

81

What are the secondary arterial supplies of the breast?

Thoracoacromial artery

intercostal artery

82

What artery is used for the CABG procedure?

card image

Internal Mammary

83

What veins drain the breast?

Internal Mammary Vein

Axillary Vein

Subclavian Vein

Intercostal Veins

84

How does breast cancer most frequently spread?

blood flow routes

85

What vein is commonly blamed for breast cancer metastasis to ribs?

Intercostal Veins - communicates with vertebral veins

86

What is the most common metastasis of Breast Cancer?

bone

lung

liver

87

Why is the axillary lymph node chain important in predicting the spread of breast cancer?

75% of lymphatic drainage is the the axilla

88

How do you identify the sentinel lymph node

A surgeon injects a radioactive substance, a blue dye, or both near the tumor to locate the position of the sentinel lymph node. The surgeon then uses a device that detects radioactivity to find the sentinel node or looks for lymph nodes that are stained with the blue dye.

89

Why is the sentinel lymph node important?

if the sentinel lymph node is clear then the rest will be clear.

90

Explain the Lymphatic drainage of the breast.

Most lymphatics of the breast first drain superficially to the anterior mammary fascia.

Then to the periareolar plexus and the axilla

91

What is the most common cancer to metastasize to the breast?

Melanoma

92

True or False?

Metastatic disease of the breast from another primary cancer is uncommon.

True

93

What is the pancake view?

medio-lateral oblique

94

What is the omelet view?

cranio-caudal

95

What is a stand-off pad

allows for greater detail in the superficial layers of the breast

96

What is the ideal thickness of a stand-off pad?

1 cm

97

What would you explain to the patient about a breast exam?

The sonographer should explain to the patient that the exam is being performed to visualize the breast and to investigate mammogram findings

98

How should a patient dress for a breast exam?

The patient should undress from the waist up and wear a hospital gown open in the front.

99

What transducer should be used on a breast exam?

7 – 12 MHz linear array transducer

100

What do you do if the mass is larger than the footprint?

change to a curvilinear probe.

101

What positions should be used for a breast exam?

Supine

Supine oblique may be used for the lateral margin of the breast

102

What are the scan planes for a breast exam?

radial and anti-radial, sagittal and Transverse

Radial plane – runs parallel to the ducts, the transducer is held at a radial plane with the nipple in the center.

Anti-radial plane – runs perpendicular to the ducts

103

What is a radial & anti-radial scan plane?

radial - runs parallel to the ducts, the transducer is held at a radial plane with the nipple in the center.

Anti-radial plane – runs perpendicular to the ducts

104

What techniques can be used during a breast exam?

Fremitus: Have the patient hum with power Doppler, everything lights up except for mass

Ipsilateral arm is raised above the head -- provides a more stable scanning surface

Stand-off pad to visualize superficial structures

Gentle but firm pressure - forces tissues into a parallel plane

105

Describe the anatomy of the breast.

The breast lies anterior to the 6th rib and pectoralis muscles. Breast tissue is supported by cooper’s ligaments that extend from deep muscle fascia to the skin. The breast is described in layers.

106

What does the Subcutaneous Layer consist of?

Consists of skin and adipose tissue.

107

What does the Mammary Layer consist of?

Consists of 15 to 20 lobes containing glandular tissue, ducts, fat lobules and connective tissue.

108

What does the Retromammary Layer consist of?

Consists of fat lobules, connective tissue and muscle.

109

What are appropriate reasons for the breast exam?

Mass found by palpitation

Mass found by mammogram

Differentiate

  • Simple cyst
  • Complex cyst
  • Solid mass
110

What are appropriate History Questions for a breast exam?

When was the last time you had menstrual Period?

Are you in pain?

Where is your pain located?

How long have you been in pain?

How long does the pain last and does it go away?

Are you experiencing any other symptoms?

Do you have a family history of breast cancer?

Have you had any lab work done?

111

What are the required images in a breast exam?

Document the lesion in at least two planes.

  • Lesions
  • Lesion w/measurements
112

What is the sonographic appearance of the Subcutaneous Layer?

Most superficial layer, The skin appears as a hyperechoic border. Inferior to the skin is the subcutaneous fat lobules which appear as low-level echoes with hyperechoic margins

113

What is the sonographic appearance of the Mammary Layer?

Mix between fat and glandular tissue, Depending on the fat content the parenchyma can appear highly echogenic with little fat or areas of low echogenicity mixed with areas of high echogenicity.

114

What is the sonographic appearance of the Retromammary Layer?

Generally hypoechoic relative to the mammary layer. Inferior to the breast the pectoralis muscle can be seen as a hypoechoic area.

.

115

What is the sonographic appearance of breasts in young patients?

Young patients have little fat and dense breasts will appear highly echogenic.

116

What is the sonographic appearance of breasts in child-bearing age patients?

Women of child-bearing age have an increase in fibrous tissue and dense connective tissue which will cause the breast to be highly echogenic.

117

What is the sonographic appearance of breasts in post-menopausal patients?

As the patient ages the glandular tissue shrinks. The breast appears hypoechoic

118

What are normal variants of breasts?

Amastia

Polymastia

Athelia

Amazia

Unilateral early ripening

Nipple inversion

119

What is Amastia?

complete absence of one or both breasts

120

What is Polymastia ?

an accessory breast

121

What is Athelia ?

an accessory nipple

122

What is Amazia ?

nipple but no breast tissue

123

What are the measurements for a breast exam?

Simple cyst: record at least greatest dimensions

Solid lesions: record all 3 dimensions

Multiple lesions: record largest and smallest

Ducts: 2-3 mm

124

What are benign conditions?

noncancerous disorders that can affect the breast

Sonographic Appearance:

Round, oval

Wider than tall

Thin walls

Anechoic, hyperechoic, homogenous

Posterior enhancement

Edge shadowing

Calcifications

Along Fibrous planes

Ducts measure 2-3 mm

Doppler – no flow

Presentation: breast lump, redness, pain, tenderness swelling, multiple cysts, palpable superficial, spherical nodule, discharge, nipple retraction , feeling of fullness, subareolar thickenin

125

What is the Sonographic Appearance of benign breast lesions?

Round, oval

Wider than tall

Thin walls

Anechoic, hyperechoic, homogenous

Posterior enhancement

Ducts measure 2-3 mm

Doppler – no flow

126

What are the presentations of women with benign breast conditions?

breast lump

redness

pain

tenderness swelling

multiple cysts

palpable superficial

spherical nodule

discharge

nipple retraction

feeling of fullness

subareolar thickening

127

What are Malignant conditions?

cancerous disorders that can affect the breast

128

What is the Sonographic Appearance of malignant breast lesions?

Taller than wide

Angular, ill-defined, microlobulations

Thick borders

Echogenic halo

Almost anechoic, heterogenous

Shadowing

Color Doppler - more peripheral and internal flow

Invade tissue planes

129

What is a simple cyst?

benign breast condition

Very common in women ages 35 to 50

Results from obstructed duct or hormonal changes

Regress after menopause

Presentation: breast lump, pain & tenderness

130

What is the Sonographic Appearance of simple cysts?

card image

Oval or round

anechoic

smooth walls

well circumscribed shape

posterior enhancement

edge refraction

sharp anterior and posterior borders

reverberation

131

What is a Complex Cysts?

benign breast condition

contain some low level internal echotexture or intra-cystic debris.

Risk of malignancy among complicated breast cysts is thought to be 0.3-2%

132

What is the Sonographic Appearance of Complex Cysts?

Low to medium echogenicity

Irregular walls

hetertogenous

fluid filled levels

septations

wall thickening

debris

varying degrees of shadowing

133

What are the presentations of Complex Cysts?

breast lump

134

What is Galactocele?

benign breast condition

Milk filled cyst, results from obstructed duct after childbirth

135

What is the Sonographic Appearance of Galactocele?

card image

Round

Hyperechoic

Homeogenous

136

What are the presentations of Galactocele?

breast lump

137

What is a Sebaceous Cyst?

benign breast condition

Superficial, sebum containing, results from obstructed sebaceous gland

138

What is the Sonographic Appearance of Sebaceous Cyst?

card image

Small

Hypoechoic

Close to the skin surface

Through transmission

No detectable vascular flow

Hypo- and hyperechoic alternating rings

A characteristic track may be seen extending into the skin surface

139

What are the presentations of Sebaceous Cyst?

breast lump

140

What is Fibrocystic Condition?

benign breast condition

Produce tissue alterations in both epithelial and connective tissue. Fluctuates with normal hormonal cycles

141

What is the Sonographic Appearance of Fibrocystic Condition?

card image

Multiple cysts

Well circumscribed thins walls

Increased fibrous stroma

142

What are the presentations of Fibrocystic Condition?

multiple cysts, pain & tenderness.

143

What is Fibroadenoma?

benign breast condition

Estrogen related tumor. Most common benign solid tumor of the breast.

Primarily in young women

144

What is the Sonographic Appearance of Fibroadenoma?

card image

Oval

Gently lobulated

Hyperechoic

Uniform echogenicity

Smooth distinct borders

Wider than tall

Enhancement

Edge shadowing

Arise from TDLU

Pseudo-encapsulated

145

What are the presentations of Fibroadenoma?

Painless palpable mass, firm rubbery

146

What is Lipoma?

benign breast condition

Encapsulated tumor of mature adipose tissue.

147

What is the Sonographic Appearance of Lipoma?

card image

Well-defined

Oval

Thin smooth walls

Homeogenous

hyperechoic

Isoechoic with fat

Enhancement

Edge shadowing

no calcification

148

What are the presentations of Lipoma?

Asymptomatic, painless palpable breast lump which is soft and mobile

149

What is Fat Necrosis?

benign breast condition

May be caused by trauma to the breast or other disease present

150

What is the Sonographic Appearance of Fat Necrosis?

card image

Irregular complex mass

Low-level echoes

Edge shadowing

Separate from breast parenchyma

Mimic malignant tumor

151

What are the presentations of Fat Necrosis?

palpable superficial, spherical nodule

152

What is Acute Mastitis?

benign breast condition

Inflammation of the breast, lactational is most common. Antibiotics

153

What is the Sonographic Appearance of Acute Mastitis?

card image

Blurred tissue planes

Skin thickening

Ductal dilation

Increased color flow

154

What are the presentations of Acute Mastitis?

localized or whole breast, Redness, pain and swelling

155

What is Chronic Mastitis?

benign breast condition

Inflammation of the glandular tissue, usually found in older women

156

What is the Sonographic Appearance of Chronic Mastitis?

card image

Difficult to differentiate by ultrasound

Diffused echo patterns

Thickening of connective tissue

157

What are the presentations of Chronic Mastitis?

discharge, nipple retraction, subareolar thickening

158

What is Abscess?

benign breast condition

complication of mastitis, usually in subareolar region

159

What is the Sonographic Appearance of Abscess?

card image

hyperechoic

Complex

Irregular borders

Posterior enhancement

Skin thickening

Increased color flow

160

What are the presentations of Abscess?

painful lump, swelling, nipple discharge

161

What is Gynecomastia?

benign breast condition

Enlargement of the male breast

Causes include – hormonal changes, testicular failure, neoplasm, marijuana, klinefelters (XXY)

Lab Values: ↑Estrogen, ↓Testosterone

162

What is the Sonographic Appearance of Gynecomastia?

card image

nodular pattern

dendritic pattern

diffuse glandular pattern

163

What is Cystosarcoma?

benign breast condition

A rare disease mostly benign breast neoplasm

164

What is the Sonographic Appearance of Cystosarcoma?

card image

Large

Hypoechoic tumor

Well-defined

Decreased through transmission

Fine or course internal echoes

Variable amounts of shadowing

165

What are the presentations of Cystosarcoma?

small breast mass that suddenly enlarges

166

What is Intraductal Papilloma?

benign breast condition

Benign tumor originating from the ductal epithelium and projecting into the lumen of the duct. Commonly in women ages 35 to 55.

167

What is the Sonographic Appearance of Intraductal Papilloma?

card image

Less than 2 mm

Subareolar region

broad-based

pedunculated

fibrovascular stalk

168

What are the presentations of Intraductal Papilloma?

bloody discharge, feeling of fullness or pain in the areola

169

What is Ductal Carcinoma in Situ (DSIS)?

malignant breast condition

Most common non-invasive breast cancer. Arises from the TDLU, malignant changes of the ductal epithelium without extension past basement membrane.

Excellent cure rate

170

What is the Sonographic Appearance of Ductal Carcinoma in Situ (DSIS)?

card image

Calcifications

Ductal enlargements

Extensions within the ducts

171

What is Invasive Ductal Carcinoma (IDC)?

malignant breast condition

80% of Breast cancer. Begin in the duct and invade the fatty tissue. Potential for metastases

172

What is the Sonographic Appearance of Invasive Ductal Carcinoma (IDC)?

card image

Calcifications

Ductal enlargements

Invasion of the breast parenchyma

173

What is Lobular Carcinoma in Situ(LCIS)?

malignant breast condition

precancerous, considered lobular neoplasm.

174

What is the Sonographic Appearance of Lobular Carcinoma in Situ(LCIS)?

card image

Confined to the gland

Difficult to distinguish with sonograms

175

What is Invasive Lobular Carcinoma (ILC)?

malignant breast condition

10 to 15% of breast cancer, begins in the duct and invades the fatty tissue. Potential for metastases.

176

What is the Sonographic Appearance of Invasive Lobular Carcinoma (ILC)?

card image

Begins in the lobule

Extends into fatty tissue

Bilateral

Multicentric

multifocal

177

What is Comedocarcinoma?

malignant breast condition

Intraductal solid carcinoma ducts filled with yellow paste-like that resembles a plug.

178

What is the Sonographic Appearance of Comedocarcinoma?

Microcalcifications

Irregular borders

Diffuse internal echoes

shadowing

179

What are the presentations of Comedocarcinoma?

pain, sensation of insects crawling, nipple retraction, dominant mass, clear discharge

180

What is Juvenile Breast Cancer?

malignant breast condition

Similar to DCIS & IDC found in girls 8 to 15.

181

What is the Sonographic Appearance of Juvenile Breast Cancer?

card image

Calcifications

Ductal enlargements

Extensions within the ducts

182

What is Papillary Carcinoma?

malignant breast condition

Tumor that arises as an intraductal mass. 1% – 2% of Breast Cancer

183

What is the Sonographic Appearance of Papillary Carcinoma?

card image

Hypoechoic solid mass

Posterior enhancement

Complex cystic and solid masses may be evident.

Relatively vascular

184

What are the presentations of Papillary Carcinoma?

bloody discharge, palpable mass

185

What is Paget’s Disease?

malignant breast condition

Rare tumor, arises in the retroareolar duct and grows toward the nipple.

Women over 50

186

What is the Sonographic Appearance of Paget’s Disease?

card image

Retroareolar Mass

Irregular borders

Hetergenous internal echoes

Posterior enhancement

187

What are the presentations of Paget’s Disease?

rash—like appearance

188

What is Scirrhous Carcinoma?

malignant breast condition

intraductal tumor with extensive fibrous tissue.

189

What is the Sonographic Appearance of Scirrhous Carcinoma?

Focal calcifications

Dense

fibrous

190

What are the presentations of Scirrhous Carcinoma?

firm nodule, nonmovable mass

191

What is Medullary Carcinoma?

malignant breast condition

densely cellular tumor.

192

What is the Sonographic Appearance of Medullary Carcinoma?

card image

Large

Resemble fibroadenoma

Oval

Gently lobulated

Hyperechoic

Uniform echogenicity

Smooth distinct borders

Wider than tall

Enhancement

Edge shadowing

193

What are the presentations of Medullary Carcinoma?

Discoloration of the overlying skin, bilateral

194

What is Colloid Carcinoma?

malignant breast condition

rare ductal carcinoma 3% of breast cancer

195

What is the Sonographic Appearance of Colloid Carcinoma?

card image

Salt & Pepper echotexture

Resemble fibroadenoma

Oval

Gently lobulated

Hyperechoic

Uniform echogenicity

Smooth distinct borders

Wider than tall

Enhancement

Edge shadowing

196

What are the presentations of Colloid Carcinoma?

slow-growing, smooth non-firm palpable mass.

197

What is Tubular Carcinoma?

malignant breast condition

Infectious cystic disease common in sheep herders, a tapeworm that infects.

198

What is the Sonographic Appearance of Tubular Carcinoma?

card image

Heterogeneous

Hypoechoic mass

Angular or ill-defined margins

Posterior shadowing

199

What are the presentations of Tubular Carcinoma?

firm palpable mass