Breast US Quiz

UT 303 - small parts 1

Galactocele

• retroareolar mass developed shortly after childbirth from the occlusion of a lactiferous duct

• sonographically - oval, circumscribed, fat/fluid levels that shift position, posterior enhancement, no blood flow

Hamartoma

• varying amount of normal or dyplastic fibrous, epithelial, and fatty breast tissue

• sonographically - oval, mixed echo pattern, compressed surrounding tissue

Fibroadenoma

• most common type of benign solid mass in breast

• sonographically - oval, circumscribed, homogenous, solid mass, often shows vascularity

Gynecomastia

enlargement of breast tissue in men

Complex cyst

• contains both solid and cystic components

• thick walls or thick septations

Ipsilateral

belonging to or occurring on the same side

Heterogenous cyst

texture is irregular, not smooth

Sebaceous cyst

cyst located within the dermal layer and has a tract connecting it to the skin

Phyllodes tumor

rare breast tumor that originates from the connective tissue of the breast and grows in a leaflike pattern, can be benign

Acini

milk producing glands

Inflammatory carcinoma

• rare and aggressive form of breast cancer

• symptoms: reddening and swelling, may or may not have distinct lump, skin looks like an orange peel

• sonographic appearance: thick, echogenic skin, dilated lymph vessels and veins, and hypervascular

BI-RADS

Breast Imaging Reporting and Data System

Benign mass characteristics

• oval, round shape

• parallel orientation

• well-circumscribed borders

• abrupt interface

• enhancement or some shadowing

• surrounding tissue is compressed

• gross calcifications

• no vascularity

Malignant mass characteristics

• irregularly-shaped

• taller than wide orientation

• indistinct, angular, microlobulated, or spiculated borders

• echogenic halo (desmoplasia)

• posterior shadowing, sometimes enhancement, or combination of enhancement and shadowing

• duct changes, cooper’s ligaments changes, edema, architectural distortion, skin thickening, skin retraction

• microcalcifications

• vascularity present within or around lesion

Noninvasive carcinoma

has not spread, confined within duct/lobule

DCIS (ductal carcinoma in situ)

• Most common noninvasive cancer that has not spread beyond the milk duct, but its presentation means an increased risk in future invasive cancer

• Typical cure rate - 99-100%

LCIS (lobular carcinoma in situ)

arises in lobules

Invasive carcinoma

has spread to surrounding tissue

Invasive ductal carcinoma (IDC)

• most common

• found most common in UOQ

Invasive lobular carcinoma (ILC)

higher rate of being multifocal, multicentric, and bilateral

Paget disease (of the nipple)

Involves reddening, ulceration, eczema-like crusting of the epidermis of the nipple and areola

Subgroups of IDC

• medullary

• colloid

• papillary

• tubular

• inflammatory carcinoma

Medullary carcinoma

• Well-marginated cellular tumor containing prominent lymphocytes and plasma cells

• Discrete, round, soft, and mobile

• Rapid growing, most in UOQ

• Sonographically - oval, solid, hypoechoic, distal enhancement, echogenic halo, prominent vascularity

Colloid (mucinous) carcinoma

• Uncommon, circumscribed gelatinous lesion

• Slow growing with high and low density

• Sonographically - oval, circumscribed, with possible lobulation and microlobulation, isoechoic/hypoechoic, homogenous or mildly heterogenous

Papillary carcinoma

• Malignant transformation of large duct papilloma

• Focal/multifocal; slow growth

• Intracystic (complex lesion with solid and cystic components or mural node)

• Grows extensions/branches into adjacent ducts

tubular carcinoma

• incites prominent reactive fibrosis

  • Slow growth

  • Starts often in TDLUs or from radial scars

  • Has thick echogenic halo and frank spiculation

  • Sonographically - small, irregular, hypoechoic with frank speculation or surrounded by a thick echogenic halo; acoustic shadowing; skin retraction

Breast anatomy

• Fat

• Ducts

• Lobules/TDLUs

• Nipple

• Areola

3 layers of the breast

• Subcutaneous fatty layer (premammary zone)

• Fibroglandular layer (mammary zone)

• Retromammary zone

Subcutaneous fatty layer

• Pre-mammary zone

• Cooper ligaments here

  • Fibrous connective tissue that shapes and supports breasts

Fibroglandular layer

• Mammary zone

• 15-20 lobes per breast, 20-40 TDLUs per lobe

Terminal ductal lobular units (TDLUs)

• Functional units of the breast

• Produces milk during lactation

Retromammary zone

Made of fatty tissue and separates pecs from mammary zone

Muscles behind breast

• Pectoralis major - beneath the upper ⅔ of breast

• Pectoralis minor - sits behind the pectoralis major

A

Skin

B

Fat lobule

C

Cooper ligament

D

Fibroglandular zone

E

Muscle

BI-RADS 0

Incomplete, needs more information

BI-RADS 1

negative, routine age-appropriate screening

BI-RADS 2

• benign, routine age-appropriate screening

• image: cyst

BI-RADS 3

• probably benign, 6-month follow up with continued periodic surveillance

• image: fibroadenoma

BI-RADS 4

• suspicious, tissue diagnosis (biopsy)

• image: US does not show all the features of a fibroadenoma, no posterior enhancement

BI-RADS 4A

low suspicion, tissue diagnosis (biopsy)

BI-RADS 4B

intermediate suspicion, tissue diagnosis (biopsy)

BI-RADS 4C

moderate suspicion, tissue diagnosis (biopsy)

BI-RADS 5

highly suggestive of malignancy, tissue diagnosis (biopsy)

BI-RADS 6

known biopsy-proven malignancy, surgical excision when clinically appropriate

Young breast parenchyma

dense echogenic pattern and fibrous tissue elements

Pregnant/lactating breast parenchyma

larger and denser glandular portions, less echogenic

Mature breast parenchyma

fatty tissue starts replacing glandular tissue

Postmenopausal breast parenchyma

ducts atrophy and fibrous tissue replaced by fat

Where do most cancers and precancers in the breast occur?

mammary/fibroglandular layer in the TDLUs

What is one of the main advantages of US when looking at the breast?

• Original role of US in breast imaging is to differentiate between cystic and solid lesions

• Does not use ionizing radiation

• Only real time imaging modality

Normal lymph node appearance

• Oval, reniform (kidney-shaped)

• Circumscribed, smooth margins

• Symmetric hypoechoic cortex with hyperechoic fatty hilum

• Doppler flow at hilum 

• Intramammary nodes < 1 mm

Abnormal lymph node appearance

• Rounded, lobulated, irregular shape

• Enlarged diameter

• Eccentric cortical thickening

• Displayed, indented, or absent fatty hilum

• Markedly hypoechoic cortex

• Heterogenous cortex

• Indistinct cortical wall

• Transcapsular blood flow

• Side asymmetry

What is the relationship between menopause/HRT and how are fibrocystic breasts affected?

• HRT (hormone replacement therapy) replaces the hormones women stop producing during menopause

• Normally, as women age, symptoms of fibrocystic breasts diminish after menopause

• If women take HRT, symptoms of fibrocystic breasts are unchanged

Prolactin

• Stimulates milk production

• Baby suckling → pituitary gland releases prolactin → stimulates additional milk production from the acinis

Radial vs. anti-radial scanning planes

• Radial - follows course of the ducts

• Anti-radial - perpendicular to radial plane

___ are the gold standard and widely used for screening of breast cancer

mammograms

What breast lesion is most affected by estrogen?

Fibrocystic breast disease, breast cancer (any type), fibroadenomas, gynecomastia

The breast parenchyma is made of ___ lobes

15 - 20

Where does primary breast cancer metastasize?

1. ipsilateral lymph node

2. lungs

3. brain

4. liver

Where do most breast cancers occur?

UOQ (in the mammary zone)

American women’s lifetime risk of breast cancer is

1 in 8

Male breast cancer makes up ___ of breast cancers

1%

symptoms of fibrocystic breasts

• tenderness

• pain

• fullness

• nodularity

• nipple discharge

• bilateral masses associated with menses

• rope-like texture

cyst on ultrasound

• anechoic

• oval or round

• well-circumscribed, smooth borders

• horizontal

• posterior enhancement, through transmission

cyst on mammogram

Circumscribed radio opaque oval/round mass

Fibroadenoma on ultrasound

• Hypoechoic

• Often oval or round, sometimes macrolobulated

• Well-circumscribed, smooth borders

• Horizontal

• Sometimes minimal posterior enhancement

• Sometimes gross calcifications

Fibroadenoma on mammogram

Circumscribed radio opaque oval/round mass

infected cyst

cyst features worrisome for acute inflammation or infection include uniform isoechoic wall thickening, hyperemia of the cyst wall, and possible internal fluid debris level

cancer metastasis to breast

• melanoma

• leukemia

• lymphoma

A

RUOQ

B

RUIQ

C

LUIQ

D

LUOQ

E

RLOQ

F

RLIQ

G

LLIQ

H

LLOQ