8/28/2016

BreastUltrasonography:Overview,Technique,InvasiveUltrasonography

BreastUltrasonography
Author:DurreSabih,MBBS,MSc,FRCP(Edin)ChiefEditor:GowthamanGunabushanam,MD,FRCR
more...
Updated:Feb20,2014

Overview
Background
Thefirstknownclinicaluseofbreastultrasound(US)wasreportedin1951byWild
andNeal, [1]whousedAmodesonographytodescribethefeaturesofonebenign
andonemalignantbreastmass.Severalattemptsweresubsequentlymadeto
developautomatedormultitransducerscannerstoevaluatethewholebreast,both
todetectsubclinicaldisease(screening)aswellasforlesioncharacterization. [2]
The1970ssawadeclininginterestinbreastultrasound,and,formorethana
decadethereafter,ultrasoundwasrelegatedtodifferentiatingsolidfromcystic
masses.However,withincreasingresolutionandqualityofUSimaging,interestin
itsuseforevaluationofthebreasthasresurged. [3]
Animagedepictingthebreaststructuresvisibleonultrasoundcanbeseenbelow.

Diagrammaticrepresentationofbreaststructuresvisibleonultrasound.

Indications
Ultrasoundisprimarilyusedinthediagnosticsettinginthepresenceofapalpable
abnormalityorwhenapreviousmammogramhasdemonstratedafocallesion.To
itsadvantage,bothdenseandfatreplacedbreastscanbewellevaluated.
Majorindicationsincludethefollowing:
Palpableabnormality
Focalabnormalityonmammography
Breastpain
Nippledischarge
Followupoflesionsnotbiopsied(mostlyBIRADS3lesions)
Determinationoflesionextentinpatientswithsuspiciousormalignant
nodules
Assessmentofregionallymphnodesinpatientswithsuspiciousormalignant
lesions
Guidinginterventionalprocedures
Attemptshavebeenmadetoestablishaplaceforultrasoundinscreening,andthe
researchersconductingtheAmericanCollegeofRadiologyImagingNetworkwhole
breastultrasoundscreeningtrial(ACRIN6666)arereportinggoodearlydata.Given
thelaboriousprotocolofscreeningwholebreasts,widespreadscreeningapplications
areexpectedtoappearonlywhenautomatedbreastscannershavedemonstrated
easeofuseandasensitivityandspecificitycomparabletohandheldbreast
screening.

Contraindications
Ultrasoundisinherentlyoperatordependent,breastultrasoundevenmoresothus,
amajorcontraindicationwouldbeinadequateoperatorexperience.

Equipment
Ultrasoundequipmentwithahighresolutionlineartransducerisnecessary.
Transducerswith7MHzto12MHzfrequencyarepreferredbecauseofbetternear
fieldresolution.

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Toodeepafocuscausesvolumeaveragingartifactsandgiveserroneousresults
abouttissueconsistency.Matrixprobesthatcanbefocusedintheshortaxisaswell
offerbetterresolution.
Evenwithhighresolutionprobes,thefocalzone(indicatedbymovingsmall
arrowheadsatthesideofthescreen)mustbekepteitheratthelesionorjustdeep
toitforbestresolution.
Machineswithpanoramicview(extendedfieldofview)optionsareoftenuseful
becausethisallowsverylargeareastobecollatedintoasingleimage.Some
machinesofferanextendedimagingfield(trapezoidimaging)whileinothers,the2
splitfieldscanbeappendedtoimagemoreofalargerlesion.However,notethat
onemustavoidusingthepanoramicimagesformeasurements.
Currentgenerationultrasoundmachinesofferadditionalimageprocessingfacilities,
includingspatialcompounding,specklereduction,harmonicimaging,andspeedof
soundimagingthatofferenhancedresolution.Thesemodesshouldbeusedand
optimizedforeachpatient. [4]
Additionalfeaturesincludeelastographythatcolorcodestissuehardness,adding
informationthatcanbeusefulincertainconditions,aswellasmicrocalcification
imagingthatenhancesthepresenceofcalciumparticles.
Anacousticstandoffpadishelpfulinimagingverysuperficiallesions.
Machinesettingsshouldbeoptimizedforbreastultrasound:thisincludes
appropriatefocaldepth,anoptimalgain,andtimegaincompression(TGCusually
thedefault,withoutanycurve),ahighdynamicrange,contrastandhighedge
enhancementsettings.Thedepthoffieldshouldextendtothepleuralechoes.
Whenoptimized,thefatshouldappearmediumgrayinthepremammaryaswellas
theretromammaryspace.

Positioning
Generallythefollowingpositionsareused:
Mediallesions:Thepatientissupine,withtheipsilateralarmoverpatients
head.
Laterallesions:Thepatientisoppositeposterioroblique,withtheipsilateral
armoverthepatientshead.Thedegreeofobliquitydependsonthebreast
size,pendulousness,andthelocationofthelesionwithinthebreast.Ina
largebreast,acompletedecubituspositionmightbethebest.
Ifalesionissuperficiallylocatedandispalpableintheerectposition,the
patientshouldbeexamined,atleastforapartoftheprocedureinthis
position.Rememberthatthebreastappearsthickerintheerectposition,so
thisisnotappropriateforposteriorlesions.
Superiorlesions:Thepatientissupine,oppositeposteriorobliqueorsitting,
withtheipsilateralarmoverthepatientshead.
Inferiorlesions:Thepatientissupine,andthebreastcanbeheldsuperiorly.
Varyingdegreeofpressureisusedtoflattenthebreastparenchymaaswellasbring
theconicalsurfaceoftheglandulartissueintoamoreorthogonalplane.
Giventherealtimedynamicnatureofultrasoundimaging,andthetendencyofthe
breasttochangeitsshapewithgravity,thepatientpositionshouldbeoptimizedto
theexamination. [5]Thismaybedoneseveraltimestoallowtheacquisitionofhigh
quality,reproducibleimages.Differentpositionsareespeciallyusefulinlarge
breasts.Inadequatepositioningmaycauseportionsofthebreasttobecome
inaccessible,thebreasttofalloverthetransducerorthelesionstoappeardisplaced
onfollowupexaminations.Smallbreastswithlittlesofttissuetoglideoverthe
chestwallcanbeexaminedinthesupineposition.

Anatomy
Thebreastisamodifiedsweatglandlocatedbetweentwolayersofthesuperficial
pectoralfasciaontheanteriorthorax,betweenthesecondandsixthribs(seethe
imagebelow). [6]The2layerscansometimesbeseenbehindtheskinechoandin
frontofthepectoralmuscleechoes.

Anatomyofthebreast.

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Twelveto20ductsexist,andtheirlobules,alongwithfatandstroma,makeupthe
parenchymaofthebreast.Thebreastductsconvergeatthenippleatoneend,and,
attheotherend,theybranchtoterminateinlobules.Theductsizevariesfrom
about1mmatthelobulestoupto58mmnearthenipple.Thelobulesareonan
average3mminthegreatestdiameter.Theratiooftheparenchymatothefat
variesbytheindividualandeveninthesamewomanatdifferentagesandduring
pregnancyandlactation.
Beforemovingontobreastultrasoundanatomy,understandthatthereference
tissueinthebreastisthefat,andstructuresarelabeledashypo,iso,or
hyperechoicwithreferencetofat.
Ultrasoundshowscertaindiscretestructuresthatcanberecognized.From
superficialtodeeptheseareasfollows:
Skin:Thisisrecognizedasathinhyperechoictoisoechoiczonebetween2
thinnerhyperechoiclines.Usuallythisislessthanorequalto2mmin
thicknessbutisslightlythickerovertheareolae.
Subcutaneousfat(premammaryfat):Thisisthereferencetissue.
Premammaryfatismorehypoechoicthanfatelsewhereandhasalobular
structurewiththefatlobulessurroundedbyaverythinechogeniclayer.
Parenchyma:Thislayerappearsasanechogenicplatethiscanbe
homogenousinsomewomenbutcanbeheterogeneous,almosttigroidin
appearanceinothers,especiallyinyoungwomen.Thiscanalsovaryin
echogenicityfromechogenicinusualcasestoalmostisoechoicinlactating
breasts.Withintheparenchymaducts,theterminalductallobularunit
(TDLU)canbeseenoccasionally.
Theductscanbeseenasthinechogeniclinesrepresentingcollapsedandapposed
ductwalls,orlinessurroundedbyahypoechoiczonethatistheloosestromaltissue
surroundingtheducts.Frequently,onlytheisoechoicperiductalstromaltissueis
seen,givingthealmoststriped(tigroid)appearance.Withprogressiveaccumulation
ofintraductalfluid,theductscanappearastubesthatcanbeupto5mmacross.
Ductectasiabecomesmorefrequentwithage,andalmost50%womenhaveectatic
ductsbytheageof50years.Ductectasiaismostlyanincidentalfindingbutmay
beassociatedwithdischargeandperiductalmastitis.
Withveryhighresolutionimages,TDLUsaresometimesseenassmallhypoechoic
elongatedorroundedstructures.Theseareusuallylocatedperipherallyinthe
parenchymalplate,morenumerousintheanteriorpartthantheposteriorpart. [7]
Cooperligamentsattachtotheparenchymalsurfacefromtheanteriormammary
fasciaandcanbeseenasthinechogenicbands,wideningastheseinsertintothe
anteriorparenchymalsurface.AfewCooperligamentsareseenposteriorlyaswell.
Formoreinformationabouttherelevantanatomy,seeBreastAnatomy.

ContributorInformationandDisclosures
Author
DurreSabih,MBBS,MSc,FRCP(Edin)FRCP(Edin),Director,MultanInstituteofNuclearMedicineand
Radiotherapy(MINAR),NishtarHospital,Pakistan
Disclosure:Nothingtodisclose.
ChiefEditor
GowthamanGunabushanam,MD,FRCRAssistantProfessor,DepartmentofDiagnosticRadiology,Yale
UniversitySchoolofMedicine
GowthamanGunabushanam,MD,FRCRisamemberofthefollowingmedicalsocieties:AmericanRoentgen
RaySociety,ConnecticutStateMedicalSociety
Disclosure:Nothingtodisclose.

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