Breast

Superficial Parts

Ratio of women to develop breast cancer

1:8

What is the second leading cause of death in women ages 40-59

breast cancer

What is the gold standard for breast health

mammography

When should yearly mammograms start?

age 40

WHEN THERE ARE NO OTHER RISK FACTORS

Why use ultrasound in breast health?

less radiation exposure

easier to see through dense tissue

allows imaging deep to the chest wall with minimal pain

doppler allows for flow detection

Breast ultrasound limitations

operator and equipment dependent

microcalcifications not easily imaged

some masses have similar characteristics to tissues whether benign or malignant

Patient history that is critical

age

location of any lumps

history of trauma to the breast

previous surgery

Indications for ultrasound

evaluate a palpable mass in women < 30 years or pregnant/lactating

pain, skin redness, nipple changes

correlate questionable findings on a mammogram

evaluate breast implants

evaluate dense breast

monitoring benign mass

evaluate axillary lymph nodes

When do mammary glands begin to develop?

4th week of embryonic life

Milk line

breast develop along a line extending from the axilla to the inguinal region bilaterally

Where are accessory or supernumerary breasts found?

milk line

Unilateral early ripening goes hand in hand with:

precocious puberty

MOST COMMON breast anomaly

polythelia

Polythelia is MORE COMMON in

males

Polymastia

accessory breast or more than two breasts

Polymastia is MORE COMMONLY found

in the axilla

Athelia

absent nipple

Amastia

absence of one or both breasts

Amazia

absence of the breast tissue with development of the nipple

may occur secondary to radiation exposure or surgical excision

Where are the breasts located at on the chest

2nd-3rd rib superiorly

6th-7th costal cartilage inferiorly

axillary line laterally

sternum medially

Tail of Spence

breast tissue extends towards the lateral upper margin of the chest into the axilla

Layers of the breast

skin

subcutaneous layer (pre-mammary layer)

mammary layer (glandular)

retromammary layer

pectoralis major

pectoralis minor

chest wall

Breast fat is more ______

hypoechoic

Where is the skin the thickest at

the base of the breast

Areola

smooth muscle, circular, and darker pigmentation of the skin that encircles the nipple

contains numerous sebaceous glands called Montgomery’s glands

Nipple

consists of dense connective tissue and erectile muscle

contains many sensory nerve endings

15-20 lactiferous ducts openings may be seen

The subcutaneous layer contains:

Cooper’s ligaments (provides support)

Where will fat not be seen?

posterior to the nipple

Why do older women have saggier breasts?

Their Cooper’s ligaments become more loose

The amount of fat in the breasts increases due to

age

obesity

pregnancy

Mammary layer is also known as

parenchymal layer

glandular layer

Axillary tail of Spence

consists of glandular tissue that extends into the axilla

stroma and epithelium

Stroma consists of:

supportive tissue of the breast

interlobular fat

connective tissue

The mammary layer is the:

functional tissue

consists of the acini. lobules, lobes, lactiferous ducts, and TDLUs

What is the smallest functional unit of the breast

acini

Acini

milk producing portion of the gland

What are the functional structures of the breast from smallest to largest

acini → lobules → lobes → breast

Lobules are composed of:

30-50 acini

intralobular terminal ducts

intralobular stromal tissue (loose connective tissue)

Where does nearly all breast pathology originate?

the TDLUs

TDLU

terminal duct lobular unit

measures 1-2 mm and not differentiated sonographically

Lobes consist of:

several TDLUs

approx. 15-20 lobes in each breast
one major lactiferous duct emerges from each lobe

(15-20) lactiferous ducts that travel towards the nipple

Lactiferous ducts

help transport milk to the nipple

Intralobular terminal duct

located within the lobule

Extralobular duct

located outside the lobule

Interlobular duct

travels between lobes

Duct slightly ______ beneath the areola

enlarges

area of lactiferous sinus

Normal lactiferous duct size

< or equal to 2 mm

Where can a lactiferous duct be larger?

at the sinus area

during pregnancy

during lactation

The deep fascia can deter:

cancer from spreading to the chest wall

The retromammary layer consists of:

thin layer of fat

connective tissue

deep layer of the superficial fascia

ALLOWS FREE MOVEMENT OF THE BREAST OVER THE CHEST WALL

The pectoralis major is ____ to the pectoralis minor and both are immediately ______ to the breast tissue

anterior; posterior

How can you prove you scanned all the way to the chest wall?

adjust the depth so the lung is the most posterior structure in the image

The male breast

normally retains some ductal elements beneath the nipple but does not develop the milk producing lobular and acinar tissue

Gynecomastia

ductal elements can hypertrophy due to hormonal fluctuations, disease processes, or medications

Males at an increased risk for breast cancer

Klinefelter syndrome (extra X chromosome)

male-to-female transsexual

history of chest wall irradiation

history of orchitis or testicular tumor

liver disease

genetic predisposition

Function of the breast

produce milk

How does estrogen stimulation change the stromal tissues

elongation of the mammary ducts

growth of connective tissue

increase in adipose tissue

increased vascularity

Progesterone stimulates :

growth of the glandular tissue (TDLU)

During pregnancy, the acinar cells enlarge in response to :

estrogen

progesterone

lactogen

prolactin

chorionic gonadotropin from the placenta

After birth, ____ and ______ diminishes and ______ dominates

estrogen; progesterone; prolactin

When do ducts and lobules return to their normal size after the termination of breast feeding?

3-6 months

Perimenopause

lobules involute

loose connective tissue turns into dense connective tissue (converts to stroma)

stroma replaced by fat

Parenchymal pattern in young females

fibrous tissue elements

dense echogenic pattern

Pregnant or lactating parenchymal pattern

larger and denser glandular portions

less echogenic interfaces

Mature parenchymal pattern

fatty tissue begins to replace glandular tissue

Postmenopausal parenchymal pattern

ducts atrophy

less fibrous tissue

Arterial supply to the breasts

lateral thoracic arteries (arises from the axillary artery)

internal mammary artery (aka internal thoracic artery) which arises from the subclavian artery

Venous drainage of the breasts

superficial veins - allows venous communication between breasts (potential route for cancer)

deep veins - drain into the internal mammary, lateral thoracic, axillary, subclavian, and intercostal veins

Lymph drainage

flow direction from the deep system towards the areola into the peri-areolar plexus and continues into the subdermal lymphatic vessels

ORIGINATES IN THE STROMA AND LACTIFEROUS DUCTS

Approx. ______ of lymph drainage is to the axilla

75%

Axillary lymph node chain

external mammary group

scapular group

axillary group

central group

subclavicular group

Interpectoral (ROTTER’s) nodes - found between the pectoralis major and minor

Level 1 lymph nodes

nodes lie lateral to the pectoralis minor muscel

Level 2 lymph nodes

nodes like posterior to the pectoralis minor

Level 3 lymph nodes

nodes lie medial to pectoralis minor

Ultrasound only is considered a good screening when:

its in conjunction with mammo

Indications for a whole breast exam

secretions

high-risk patients with dense breasts

search for lesions in known cancer patients

implant rupture

search for primary lesion

follow-up to multiple known masses

patients who refuse mammography

Patient history in breast exams

personal history of breast disease

personal history of cancer

family history of breast disease

previous breast surgeries

medications

breast pain

findings from self exams

menstrual status

Assess for

size, shape

skin thickness

redness or discoloration

retraction or protrusion

nipple discharge or retraction

surgery scars

Radial

longitudinal/ parallel to the ducts

Anti-radial

transverse or perpendicular to the ducts

Benign masses tend to move:

slightly within tissues

Malignant masses tend to move:

not as much; they are rigidly fixed

Rolled nipple technique

one finger is placed alongside the nipple and with the transducer you roll the nipple to scan parallel to the duct

Stand off pads improves the imaging of superficial structures like:

tumors

cysts

vessels

ducts

surgical specimens

skin lesions or thickening

Fremitus maneuver

vibration of tissues in the chest during speech

used to evaluate breast tissues during real-time scanning

foreign tissues will not vibrate, therefore there is no signal that is created

What is the standard method for breast scanning

clock method

123 method

describes the location of a lesion in comparison to its distance from the nipple

ABC method

describes the depth of the lesion

Common mass to find in the breast

cysts

Breast cysts commonly resolve:

after menopause

MOST COMMON cause of breast masses in pre menopause patients

fibrocystic disease

Fibrocystic disease is followed by:

adenosis (painful and lumpy breasts)

MOST COMON benign breast tumor

fibroadenoma

What age group is fibroadenomas primarily seen in

15-4;p’
“?

Fibroadenoma sono appearance

small, rounded margins

clearly delinated from surrounding breast tissue

low-level homogenous internal echoes

possible posterior enhancement

Galactocele

milk-filled cyst that forms in the breast during or shortly after breastfeeding due to a blocked duct

clinically firm, movable, subareolar lump

usually painless but can be tender if large

Mastitis

inflammation of the breast

usually during pregnancy and lactation but can affect women at any stage of life

Symptoms of mastitis

edema

nipple discharge

nipple retraction