Breast Protocol

Protocol
 Scan from nipple outward then back toward nipple including the Tail of Spence (Axillary Region)
 No pathology present - Store image anywhere along scanning section
 Pathology present - image pathology in both planes, measure, utilize color & spectral Doppler
 Protocols will vary at each site - examples of protocols that may be used are identified below

Example of a Whole Breast Examination of the RIGHT Breast

Area of Concern Plane Label Landmarks

Include the appropriate clock position
and scan plane
(scan plane only for nipple and axilla)
For Each of the Radial Radial  Skin
Following Clock  Premammary Layer
Positions  Mammary Layer
 12:00  Retromammary Layer
 3:00  Pectoralis Muscle
 6:00  Pleura/ lung
 9:00 Antiradial Antiradial  Skin
 10:00  Premammary Layer
 11:00  Mammary Layer
 Retromammary Layer
 Pectoralis Muscle
 Pleura/ lung
Areola/ Nipple Oblique under Nipple  Lactiferous Sinus
nipple
Axilla/ Tail of Spence Antiradial Axilla  Skin, Fat and Muscle

Example of a Whole Breast Examination of the LEFT Breast

Area of Concern Plane Label Landmarks
Include the appropriate clock position
and scan plane
(scan plane only for nipple and axilla)
For Each of the Radial Radial  Skin
Following Clock  Premammary Layer
Positions  Mammary Layer
 12:00  Retromammary Layer
 1:00  Pectoralis Muscle
 2:00  Pleura/lung
 3:00 Antiradial Antiradial  Skin
 6:00  Premammary Layer
 9:00  Mammary Layer
 Retromammary Layer
 Pectoralis Muscle
 Pleura/lung
Areola/ Nipple Oblique under Nipple  Lactiferous Sinus
nipple
Axilla/ Tail of Spence Antiradial Axilla  Skin, Fat and Muscle

Targeted Examination- Typically used when a pathology is seen on mammogram, previous sonogram, or is palpable

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 Breast Protocol

Clock Position Plane Label Landmarks

Identify the area of Concern by the
clock position
Identify the area of Concern by the
clock position
Identify the area of Concern by the
clock position
“Magnified”
Identify the area of Concern by the
clock position
“Magnified” with AP and Length
Measurements
Identify the area of Concern by the
clock position
“Magnified”
Identify the area of Concern by the
clock position
“Magnified” with AP and width
measurements
Identify the area of Concern by the
clock position
“Magnified” with Color Doppler of
pathology
Identify the area of Concern by the
clock position
“Magnified” with Color Doppler &
Spectral Analysis of pathology
Radial  Clock position  Skin
 Radial  Premammary Layer
 Mammary Layer
 Retromammary Layer
 Pectoralis Muscle
 Pleura/ lung
Antiradial  Clock position  Skin
 Antiradial  Premammary Layer
 Mammary Layer
 Retromammary Layer
 Pectoralis Muscle
 Pleura/ lung
Radial  Clock position  Anterior, posterior, superior,
 Radial and inferior walls of
pathology
Radial  Clock position  Anterior, posterior, superior,
 Radial and inferior walls of
pathology
Antiradial  Clock position  Anterior, posterior, and
 Antiradial lateral walls of pathology
Antiradial  Clock position  Anterior, posterior, and
 Antiradial lateral walls of pathology
Radial  Clock position  Anterior, posterior, superior,
 Radial and inferior walls of
pathology
Radial  Clock position  Anterior, posterior, superior,
 Radial and inferior walls of
pathology

Images Required for BCHS Scan Competency

 All site specific protocol images
 Area of concern radial plane images
 Area of concern antiradial plane images
 Nipple images
 Axilla images
 Pathology images

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 Breast Protocol

Anatomical/Image Correlation/Image Orientation-

http://www.obgyn.net/displayarticle.asp?page=/bh/articles/newbreasthandoutI & www.imagingce.info/.../quadLocal.gif

Normal Measurement Ranges

Structure Area of Concern Plane Measurement Comments
Skin Near field Sagittal 2-3 mm Measure Anterior to Posterior diameter
(use standoff pad or thick layer of gel)
Ducts Posterior Nipple Sagittal Less than 3 mm Measure Anterior to Posterior diameter
Lymph Axillary or Sagtital & Less than 1.5 Abnormal lymph nodes will appear round rather than oval.
Nodes wherever transverse cm in all planes Length, width, and height measurements should be taken
visualized to determine size in each plane

Sonographic Appearance
Structure Echogenicity
Skin Echogenic
All Anatomy should be compared to Glandular Tissue Isoechoic to Hypoechoic
echogenicity of FAT Fibrous Tissue Hyperechoic
Cooper’s Ligaments Hyperechoic
Fat = medium level gray Ducts Anechoic or Hypoechoic
Muscle Hypoechoic with Striations
Ribs Echogenic with shadowing
Benign Characteristics
Smooth, Macrolobulations Homogeneous Anechoic Hyperechoic Posterior Wider Thin echogenic
thin walls (3 or less enhancement than capsule
lobulations) taller
Suspicious Characteristics-Just takes one!
Irregular Microlobulations Spiculated Angular Branch Heterogeneous Taller Hypoechoic
contour margins pattern than compared to
wider fat
Thickened Micro- Disruption of tissue planes Duct Shadowing Increased echogencity
Cooper’s calcifications extension anterior to mass
ligaments

Transducer- Dependent on amount of breast tissue - high frequency linear transducer with minimum of 7 MHz is recommended

Patient Position
 Patient lies supine or slightly oblique (may need support wedge) with arm over head
 Obliqued more for larger breasts - the breast should lay flat to minimize the thickness of the breast

Pathology-- If pathology is present you must document the pathology in its entirety. Images should include:
 Gray scale sagittal and transverse images - document distance from NIPPLE not areola
 SHAPE, MARGIN, ECHOGENICITY, LESION BOUNDARY, ATTENUATION, SURROUNDING TISSUE
 Gray scale sagittal and transverse images with 3 measurements (length, width, and height)
 Color Doppler image to document the presence of blood flow and Spectral Doppler image to document type and velocity of blood
flow (Use Power/Color Doppler with humming to identify solid masses—FREMITUS)
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