Optimizing Breast Sonography
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1 Optimizing Breast Sonography Cindy Rapp BS, RDMS, FSDMS, FAIUM Denver, Colorado
2 Breast Sonography general goal to make a more specific diagnosis than can be made with clinical and mammographic findings alone
3 Breast Sonography specific goals prevent unnecessary biopsies prevent F/U mammograms guide interventional procedures improve clinical and mammographic interpretive skills find malignancies missed by clinical and/or mammographic exams
4 BUS indications -- all
5 Breast Sonography Proper Equipment
6 Breast Sonography Equipment Requires a near-field high resolution probe Spatial resolution axial resolution lateral resolution Contrast Resolution
7 Breast Sonography Equipment Lateral resolution minimize volume averaging Two planes long axis short axis or elevation plane
8 E L E V A T I O N P L A N E Breast Sonography elevation plane
9 ELEVATION PLANE FOCUS 10 MHz FL 1.5 CM Equipment lateral resolution S U B Q F A T 5 MHz FL 3.5 CM 3 CM M A M M A R Y Z O N E R E T R O M A M M A R Y PECTORALIS LUNG
10 Elevation Plane Focus SKIN Elevation Plane Focus 1.5 CM SKIN Elevation Plane Focus 1.5 CM
11 Patient Positioning right breast LPO Supine LLD
12 hand behind head thins breast and improves angles
13 Scan Planes Radial Anti-Radial LT A A RAD B B C AR C
14 Scan Planes Radial Anti-Radial
15 Ductal system Radial Anti-Radial
16 Breast Sonography normal anatomy SKIN COOPERS LIGAMENTS SUBQ FAT PRE-MAMMARY FASCIA MAMMARY ZONE RETROMAMMARY FASCIA RETROMAMMARY ZONE PECTORALIS
17 Normal Anatomy
18 apparent duct duct plus isoechoic loose periductal stromal fibroelastic tissue
19 duct ectasia virtual variant of normal
20 Breast Sonography Mammographic Sonographic Correlation
21 Breast Sonography Mammographic Densities: fat calcium water
22 Breast Sonography Mammographic Densities Water density: cyst fibrous tissue glandular tissue solid nodule muscle / skin
23 Mammographic-Sonographic Correlation Fatty Tissue RCC LCC
24 Mammographic-Sonographic Correlation Glandular Tissue RCC LCC
25 Mammographic-Sonographic Correlation Fibrous Tissue RCC LCC
26 Breast Sonography Mammographic Sonographic Correlation size shape location surrounding tissue density
27 Breast Sonography Mammographic - Sonographic Correlation Size Must take into account all that is water density
28 Breast Sonography Mammographic - Sonographic Correlation Size Always include the capsule
29 mammographic sonographic correlation size -- water density = fibrous pseudomass
30 Mammographic - Sonographic Correlation Shape 90 rotation difference
31 Mammographic - Sonographic Correlation Shape 90 rotation difference
32 Breast Sonography Mammographic - Sonographic Correlation Shape & Location Mamms compression pulls long axis perpendicular to chest wall U/S compression pushes long axis parallel to chest wall
33 mammographic-sonographic correlation location -- always closer to chest wall on US
34 Mammographic-Sonographic Correlation shape and surrounding tissue BIRADS - 4 BIRADS - 2
35 Mammographic-Sonographic Correlation if you can t find it it s solid!! -- look for capsule
36 Breast Sonography System Optimization
37 Breast Sonography
38 Breast Sonography Always Set Fat Medium Gray
39 Breast Sonography Fat set as Black Fat set as GRAY
40 Breast Sonography High-Grade Invasive Ductal Carcinoma
41 Breast Sonography Palpable Nodules
42 DIAGNOSTIC BREAST ULTRASOUND PALPABLE ABNORMALITY Specific goal #1 Can prevent biopsy by showing: Conservative Aggressive Simple cyst Fibrous pseudomass Complex cyst (most) Fibroadenoma
43 Breast Sonography Palpable Lump when the indication is palpable lump, you must palpate while scanning for larger lesions, roll finger under the probe while scanning
44 Palpable Lump Normal Fibro-Glandular Tissue
45 Palpable Lump Tension Cyst Lazy Cyst
46 Breast Sonography Simultaneous Palpation and Scanning Simple Cyst Fibroadenoma
47 Breast Sonography Standoff Pads
48 Gel standoff
49 Gel Standoff
50 Near-field Volume Averaging Palpable Lump 5 mm deep no stand-off focal zone too deep gel stand-off focal zone correct
51 Breast Sonography Split-Screen Imaging
52 Breast Sonography For Asymmetric Density Split-Screen Mirror Images
53 Breast Sonography Split Screen Mirror Images RT LT
54 Breast Sonography Split screen with and w/o compression
55 Breast Sonography Split Screens with & w/o compression for compressibility > 30% compressible - fat, lipoma 0-25% compressible - FA 0-15% compressible - CA
56 Compressibility Split-Screen Comparison X + + Lipoma X
57 Breast Sonography Fibroadenoma or Fat Lobule?
58 Breast Sonography 3 maneuvers to prove fat lobule 1) Compressibility - 30% 2) Rotate 3) Line
59 Breast Sonography Variable Compression 2D Imaging
60 Breast Sonography Split screens with & w/o compression
61 Breast Sonography Split screen with and w/o compression for rotation rotation - FA no rotation - CA
62 Breast Sonography Fibroadenoma
63 Breast Sonography Compression eradicates artifactual shadowing
64 Breast Sonography Compression eradicates artifactual shadowing
65 Breast Sonography Cancer next to cyst
66 Breast Sonography Artifactual Shadowing
67 Breast Sonography Which one is a cancer?
68 Breast Sonography Artifactual Shadowing
69 Breast Sonography Variable Compression Technique Color & Doppler
70 Variable Compression Technique Fibroadenoma
71 Variable Compression Technique Color Doppler
72 Variable Compression Technique Power Doppler
73 Breast Cysts Interpretive difficulties With improved resolution Cysts which appeared to be simple on older lower resolution equipment, may appear to have internal echoes on newer higher resolution equipment. Problem we have been taught that any cyst with internal echoes must be classified as a complex cyst and that all complex cysts are worrisome.
74 Breast Cysts
75 Breast Cysts Acorn cyst Foam cyst
76 Breast Cysts
77 complex cysts with streaming echoes cholesterol crystals
78 complicated cysts with color streaking cholesterol crystals
79 Breast Cysts Color Doppler
80 Breast Cyst Pre-aspiration Post-aspiration Foam Cyst FA
81 Breast Cysts Interpretive difficulties: These are not artifactual echoes but represent proteinaceous debris cholesterol crystals floating foamy macrophages floating papillary apocrine metaplasia Pathologist classify these findings as part of the spectrum of fibrocystic change
82 Breast Cyst Fluid Debris Level Supine Upright
83 Thin septations Breast Cyst
84 Thick septations Breast Cyst
85 Breast Cyst Eccentric Wall Thickening Acorn Cyst ICP ICP-CA
86 Breast Cyst Thick wall - Thin wall Inflamed cyst
87 Color Doppler Cystic lesions
88 cluster of cysts or solid? medullary carcinoma
89 Other breast tumors pseudo-cystic lesions lymphoma metaplastic carcinoma some high grade IDCA metastatic lesions Metastatic IML
90 Mammographic nodule complex cyst? Metastasis - uterine Leiomyosarcoma
91 Breast Sonography Fremitus Power Doppler Thrill felt by humming
92 Fremitus
93 Fremitus Multifocal Carcinoma
94 Isoechoic Lesion FA or Fat Lobule
95 Breast Sonography When is Fremitus helpful? Multifocal disease Isoechoic lesions Artifactual shadowing 12 Apostles - Australia
96 Fremit us Multifocal carcinoma Artifactual shadowing
97 Bear-ly visible Fremitus
98 Fremitus Multifocal carcinoma
99 Once you understand Breast Sonography, you ll love it!
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