In-Depth Notes on Ultrasound in Women's Health and Breast Imaging

Overview of Ultrasound in Women's Health

• Key Areas Covered:

  • Ultrasound in Obstetrics & Gynaecology (Week 3)

  • Breast Ultrasound (Week 4)

  • Scrotal and Prostate Ultrasound in Men’s Health - examples of 'small parts' imaging

Breast Anatomy

• Influences on Development:

  • Strongly influenced by female sex hormones

  • Common cyclic changes in breast structure

  • Symptoms include:

    • Pain

    • Nipple discharge

    • Lumps

Structure of the Breast

• Layers:

  • Skin

  • Subcutaneous Layer:

    • Fatty tissue with connective tissue septae.

  • Mammary Layer:

    • Comprises 15-20 lobes divided by Cooper's ligaments, each lobe opens via a lactiferous duct to the nipple

  • Retromammary Layer:

    • Loose areolar tissue

  • Pectoralis major muscle and ribs and intercoastal cartilage posterior to the retromammary layer

Cooper’s Ligaments

• Composed of fibrous connective tissue extending across breast layers

• Echogenic: visible in fatty layers, less so in glandular tissue

Indications for Breast Ultrasound

• To:

  • Characterize mammographic or palpable masses (cystic or solid)

  • Investigate masses obscured by dense tissue

  • Evaluate lesions in young, pregnant, or lactating patients

  • Identify abscesses in cases of mastitis

  • Assess breast pain or non-palpable lesions

  • Assist in interventional procedures (FNA, core biopsy)

  • Follow-up on known lesions

Ultrasound Preparation Steps

1. Obtain clinical history.

2. Review previous ultrasound and mammogram results.

3. Explain procedure to the patient.

4. Conduct physical examination, palpate areas of concern.

The Ultrasound Examination

• Use of a high-resolution linear array transducer (7.5-17.0 MHz).

• Patient positioning:

  • Supine and slightly oblique, with shoulder and torso of the side being examined elevated.

  • Arm elevated comfortably above head.

• Important to apply light probe pressure to avoid tissue compression.

Scanning Technique

• Evaluate entire breast and axillary regions:

  • Use the "o’clock method" starting at 12 o’clock and moving in a clockwise direction.

• Any detected masses must be detailed in both planes and measured in three dimensions.

Sonographic Appearance

• Normal Patterns:

  • Skin: two thin echogenic lines (up to 2 mm thick).

  • Subcutaneous layer: hypoechoic fat with hyperechoic Cooper’s ligaments.

  • Glandular tissue: moderate hyperechoic pattern, homogeneous.

  • Retromammary fat: hypoechoic.

  • Ducts: tubular structures (1-8 mm) converging at the nipple.

  • Nipple: medium-level echogenicity, hypoechoic oval structure.

Ultrasound in Breast Pathology

• Common Breast Pathologies:

  • Cysts

  • Simple:

    • Anechoic, round, sharply marginated, rear acoustic enhancement.

  • Fibroadenoma:

  • Most common benign solid mass, often discovered as a mobile mass.

  • On ultrasound:

    • Well-defined and oval, homogeneous but can exhibit heterogeneous areas.

  • Breast Carcinoma:

  • Leading cause of death in women; risk increases with age.

  • Typically appears as a hypoechoic mass with irregular borders.

  • Late signs include skin retraction and nipple discharge.

BI-RADS (Breast Imaging-Reporting and Data System)

• A tool for risk assessment and quality assurance developed by the American College of Radiology.

• It provides a common lexicon for breast imaging across modalities, including mammography and ultrasound.

Innovations in Breast Imaging

• Ultrasound Elastography:

  • Measures tissue stiffness using compression and shear wave elastography techniques.

• Associated with improving diagnostic accuracy and potentially minimizing false-negative cases of breast cancer.