Breast U/S&Mammography

Introduction :Anatomy:

The breast consists of three types of tissue: the skin, subcutaneous adipose tissue and the functional glandular tissue. Centrally, there is the nipple–areolar complex. Collecting ducts open into the tip of the nipple. There are sebaceous glands within the nipple–areolar complex called Montgomery's glands. Small raised nodular structures called Morgagni's tubercles are distributed over the areola, representing the openings of the ducts of Montgomery's glands onto the skin surface.

• The number of lobules per lobe varies according to age, lactation, parity and hormonal status. At the end of reproductive life there is an increase in the amount of adipose tissue and, although the main duct system is preserved, there is considerable loss of lobular units. These changes in breast composition are manifested by changes in the breast density on mammography.

• Usually, younger women tend to have more of the dense glandular breast tissue. In older women, the mammographic density tends to decrease, with replacement of the glandular tissue by fatty tissue. However, there are young women who have very fatty-appearing breasts on mammography and older women with mammographically dense breasts. Classifications systems have been developed to describe the density of breast tissue on mammography

• One of the best known is the Wolfe classification: • • • -Wolfe N1 pattern refers to a breast containing a high proportion of fat- Wolfe DY pattern refers to extremely dense breast tissue-Wolfe P1 pattern refers to a predominantly fatty breast with< 25% visible glandular

tissue• -Wolfe P2 pattern refers to a breast with > 25% visible glandular tissue.

• There is some evidence suggesting that there is a relationship between the mammographic parenchymal pattern and the risk of developing breast cancer. Women with dense breast tissue have a higher than average risk of developing breast cancer. In addition, dense breast tissue may hide abnormalities in the breast, making cancer detection more difficult. The sensitivity of mammography for detecting breast cancer is directly related to the density of the breast tissue. In general, mammography is more sensitive at detecting breast cancer in older, post menopausal women because the breast tends to be composed of greater amounts of fatty tissue.

• Blood supply

• Arterial supply:

• Medial: internal mammary artery• Lateral: axillary artery

lateral thoracic

thoracodorsal

intercostals

Venous drainage:• Internal mammary v: direct communication with pulmonary capillary bed,

providing major routes for hematogenous metastases• Axillary vein• Intercostal vein: direct communication.

Lymphatic drainage• Drainage from deeper

tissues of the breast Ù surface Ù skin subareolar plexus Ù axilla

• Small % : drain to upper abdomen medially to internal mammary lymphatics

Indications of U/S:• Differentiation of cysts from solid masses• Evaluation of a palpable mass not visible in

radiographically opaque breast• Evaluation of palpable mass in young patient• Evaluation of an inflammed breast for the presence of an

abscess• Evaluation of a mass that cannot be completely

evaluated by mammography because of its deep location

• Guidance for interventional procedures• For duplex colour flow.

Breast mass lesion:According to U/S finding

Cystic lesion :• reast cysts are common between age 20-50 and classified into :• -simple -complex -complicated.• Simple cyst:• U/S criteria:• anechoic center.• Thin echogenic capsule.• Acrostic enhancement.• Thin edge shadow.• Mamoghrpahic appearance:• Round,ovel ,well defined.• Halo surrounded lesion.• On follow up there is mas be disappeared, decrease or increase in size.

• N.B : carcinoma can occurs I immediate vicinity of cyst so it is necessary to survey the tissue surrounding the cyst and cyst itself.

Complex and complicated cysts:complex cysts demonstrated by at least one of

these criteria:thick wall ,thick septation, moral nodules.

Categorization complex and complicated cysts into categories help assess their risk infection and neoplasm. Complex cyst asteroids include:

• -diffuse low-level internal echoes.• -fluid -derbies level. • - septation.• -eccentric wall thickness.

1.Low -level internal echoes:• complicated cyst with low internal echoes should be evaluated for

wall thickness and particle morbidity.• If cyst has normal thin echogenic wall (isoechoic wall indicate

inflammation).• If cyst has thick wall consider acute inflammation, and should be

aspirated. • If cyst contain subcellular particle is part of spectrum of fibrocystic

changes. 2.Fluid -debris level:• cysts with fluid -debris level have wall thickness indicated

inflammation and tender , debris shift with change of patient position.

2.Septation:• Thin septation : cluster or simple cyst.• Thick septation : complex cyst(N.B: aspiration not prefer

) 3.Eccentric wall thickening:• Evaluate the wall surface characteristics , the eccentric

wall thickening is assumed to be solid nodules.• -if there is thin ,smooth echognic capsule

indicates non infiltrating leading edge more typical benign lesion.

• -If there is lake of thin capsule increase infiltrating leading age a sign of malignancy.

Solid Nodules:All solid nodules should be consider malignant lesion ,even single malignant

feature is present the nodule can't be calcified benignlesion ,if no malignant feature are found specific, and feature of benign are

found benign lesion is consider. If not found benign feature the lesion classified as intermediate type .

Malignant lesion: sure U/S criteria : -spiculation. -angular margin -microobulation -taller than wise - hypoechoic -branch pattern. -shadowing - calcification - duct extensionDoppler examination show abnormal vessels and centenary penetrating. In

contrast benign tumour as fibroadenoma show displacement of norrmal vessels around the edge of lesion.

mamoghrphic criteria :ill defined spiculated mass, many breast cancer araise from DCIS associated

with microcalcification, Architectural distortion may only clue for presence of invasive tumour.

Special type tumours can have particular mammographic characteristics:

1.Lobular carcinomas can be difficult to perceive on a mammogram due to their tendency to diffusely infiltrate fatty tissue. Compared with ductal NST tumours, lobular cancers are more likely to be seen on only one mammographic view, are less likely to be associated with microcalcifications, and are more often seen as an ill-defined mass or an area of asymmetrically dense breast tissue.

2.Tubular and cribriform cancers often present as architectural distortions or small spiculated masses.

3.Papillary, mucinous and medullary neoplasms may appear as new or enlarging multilobulated masses and may be well defined, simulating an apparently benign lesion .

4.A small spiculated mass will be easily visible in a fatty breast, whereas even large lesions can be obscured by dense breast parenchyma

DD a) Postsurgical scar

Looks different between the ML and CC projections while Ca looks the same on both

b) Fat necrosis

This patient had a biopsy with benign results 4yrs earlier. This spiculated mass, with no distinct ceneral mass with skin retraction proved to be fat necrosis.

c) Radial scar

Benign scarring process characterized by dramatic spiculation . It is idiopathic, unrelated to known trauma or surgery Excisional biopsy.

Benign lesion:

only if only suspicious malignancy finding not prsent.

U/S finding:(all are smooth and well circumscribed)

-pure and marked hyperechogencity(hyperechoic)

-elliptical wider than tall.

-thin echogenic capsule.

-three or fewer lobulation.

Most common benign lesion:

Fibroadenoma:

U/S:smooth well defined , oval lobulated ,wider than taller mass . with thin echogenic pseudo capsule

Mamoghrphic appearance: well defined ,oval mass , may show coarse calcification.

N.B:Phyloid tumour is suggested by large well defined mass with several cystic space

Lipoma.

Benign tumour composed of fat , they present clinically as soft lobulated mass.

U/S:well defined hyperechoic lesion in compared to adjacent fat .

Mamoghraphic appearance: well difined mass of fat density contained within thin capsule.

Paplioma.Benign proliferation of ductal epithelium that projects into lumen of the duct& is connected to the epithelium by a

fibrovascular stalk.Within major ducts= subareolar in location.Usually single, when multiple they occur in peripheral ducts.They extend longitudinally in the duct lumen. The duct around it can dilate forming a cyst.( Origin of “intracystic papilloma”).Presentation: serous or bloody nipple discharge ( due to their fragile blood supply leading to necrosis, infarction and

bleeding).Mammogram: - usually Ù invisible - rarelyÙ retroareolar mass - sometimes Ù subareolar microcalcification clusters lucent centered calcification

Galactography: filling defectU/S: solid, hypoechoic, usually lobulated masses within cystically dilated ducts.N.B. papillomatosis = epithelial hyperplasia

Duct ectasia.1ry affects the major ducts in the subareolar region.The distended ducts are filled with fluid or thick unresorbed

secretions and cellular debris.Etiology: 2ry to periductal inflammation. The duct may be weakened by surrounding inflammation

become patulous, filled with unresorbed debris which may calcify.

Mammogram: Tubular, serpentine structures converging to the nipple in the subareolar region

U/S: anechoic fluid filled tubular structures.With debris

Mammary dypalsia.Definition: Benign proliferation of breast stroma.Types: a)cystic form: when lactiferous ducts consist of cystic dilatation of

varying size.b)Fibrous form when changes are predominantly periductal fibrosis.c) Adenosis form: enlargement of the lobule 2ry to a benign

proliferation of the acini. This proliferation within the TDLU is 1ry an elongation and

multiplication of the acini accompanied by an overgrowth of the epithelial &myoepithelial and connective tissue elements in the lobule.

cystic dilatation of the acini is where Ca+ ppt. (D.D. Ca)

Galactocele,Occasionally a milk containing cystic structure develops

during lactation or in the months after the cessation of nursing.

Age: 20’s-30’sEtiology: Obstruction of a duct .The proximal (lobular) segment becomes distended with

inspissated milk.Clinically: it is indistinguishable from other causes of a

rounded mass.Mammogram: if the milk filled cystic mass has enough fat

content Ü well circumscribed radiolucent mass.

Placema cell mastis.These appear in one of these patterns. a) thick continuous solid, rod-shaped deposits

oriented along duct lines diffusely or segmental distributionb) Lucent centre rod-shaped calcificationc) Lucent centered globular calcificationThey are called plasma cell mastitis because of

the plasma cell infiltrate that are histologically part of the inflammatory process.

D.D. Ca calcification

Hamartoma.

roliferation of fibrous and adenomatous elements in fat surrounded by a capsule of connective tissue