Optimizing Breast Sonography - SD

Introduction to Optimization of Breast Sonography

Hi, I am Cindy Rapp from Denver, Colorado,
and today I am gonna be talking about optimization
of breast ultrasound.
Today we're gonna be talking about optimization
of breast sonography.

Goals of Breast Ultrasound

With breast ultrasound, what our general goal is, is
to make a more specific diagnosis than what can be made
with the clinical and mammographic findings alone.
More specific goals that we try
and accomplish is to prevent unnecessary biopsies.
If we can show that what the patient is feeling is a ridge
of normal fibro glandular tissue
or a simple cyst,
we can avoid having the patient have a biopsy.
We also try to prevent follow up from mammograms.
It's amazing how many patients are afraid of the amount
of radiation that they think they're going
to get from a mammogram.
So if ultrasound could answer their concerns or problems
and additional views for the
mammograms don't need to be done.
As a great goal that we can accomplish, we try
and guide interventional procedures.
If a lesion can be seen under ultrasound,
it's gonna be much easier
to biopsy it under ultrasound guidance than it is
stereotactic methods to improve the clinical
and mammographic interpretive skills.
And what I'm gonna do is show you an example
of a area on a mammogram that was given a birads four.
We scan the same patient with ultrasound
and change that BIRADS classification to A two.
Now anything that's a birads four
or five is recommended for a biopsy with the birads two.
Basically, it's saying that the area is perfectly normal
tissue and no further workup needed to be done.
And the last thing I put here is to find malignancies missed
by the clinical and or mammographic exam.
I'm not saying that ultrasound is here
to replace mammography, that is still our screening modality
of choice, but I'm sure all of you have had a patient
that had a quote negative mammogram that we were able
to find a breast cancer with ultrasound.

Indications for Breast Ultrasound

If we look at the indication as
to why we're doing breast ultrasound, number one,
indication is a palpable abnormality.
About 46% of the time patients will present
with something palpable that we scan for ultrasound.
You can see we have mammographic 32% of the time
follow up 7% the one we all hate pain.
Yes, pain is an indication for doing a breast ultrasound,
but it's kind of a time where you can help educate the
patient to let them know
that rarely is breast cancer tender.
Most of the time it's something
that shows up on the mammogram
or a palpable abnormality that they'll present with.
And if a patient presents with pain, majority
of time it's due to hormonal reasons and not an actual mass.
Then the final thing is non-targeted.
This piece of the pie is scanning just for a specific lump
or mammographic density,
and I think we're seeing more places doing whole breast
ultrasound and not just a targeted breast ultrasound.
With the concerns of patients that we see today, more
of them want to have a whole breast ultrasound.

Proper Equipment for Breast Sonography

First thing we're gonna talk about is proper equipment.
Now in doing breast sonography, you need
to make sure you have a transducer
that has excellent near field resolution.
You wanna have good spatial resolution.
This is axial and lateral
and also a good contrast resolution.
We're gonna talk more about lateral resolution.
This is what's going to help minimize volume averaging.
When we look at the transducer, there's basically two planes
to the transducer that we deal with.
The long axis of the transducer
and things that can help minimize volume averaging in the
long axis are your focal zones.
If you're looking at a lesion that's superficial,
move your focal zones up to the near field.
If you're looking deep, move your focal zones down.
But adjusting your focal zones is going to help
optimize your image and avoid volume averaging.
The other area of the transducer
that we basically have no control over is called
the elevation plane.
This is going to be the short axis
or where the beam is going
to be focused in the narrow uh view.
And if we look at a high frequency linear array transducer,
if we have a lesion that is sitting right at one
and a half centimeters in depth,
and that's where most of your high frequency linear array
transducers are focused, you can see
that the beam is narrower than the lesion.
If this is a cyst, it's going to appear cystic.
If you have a solid lesion sitting in this area,
you're going to see subtle differences between that
and the surrounding tissue.
Whereas if you're using a low frequency linear array
transducers such as a linear seven to four megahertz,
those are intended for peripheral vascular imaging.
Those transducers are focused right at about three
centimeters in depth
and on most patients,
that's just about at the pectoralis muscle.
So in using your lower frequency linear array transducer,
what you're going to notice is the lesion.
The beam is wider than the lesion.
If you have a cyst, it will fill in with echo
and look like it's solid.
If you have a solid lesion, you may not even be able
to differentiate that from the surrounding tissue.
It just becomes sort
of volume averaged into the surrounding tissue
and you may not even notice it.
So here's an example of a lesion
that scanned is very superficial.
In fact, on this patient, one
and a half centimeters of depth is right at
her pectoralis muscle.
We can see this lesion here
and basically I would have to classify this
as indeterminate.
I'm not sure if we're dealing with a cyst, if we're dealing
with a solid lesion with necrosis.
You just can't be certain
because a lesion is too superficial to the skin.
We wanna do something to get it closer
to the elevation plane focus.
So in doing that, we've taken a standoff pad,
move this closer to the one
and a half centimeters in depth
of the elevation plane focus.
And now you can see that
what we have are two simple cysts sitting adjacent
to each other and you're like, wait a minute, Cindy,
that looks like it's a lobulated lesion.
You said two simple cysts.
Well, on ultrasound, we don't see structures
that are running up towards the transducer real well.
A zero degree angle is our best angle for doppler,
but it's our worst angle for imaging.
We see structures that are parallel to the transducer face,
so something that's 90 degrees will cause a bright specular
refle reflector,
and we're gonna see that a lot better on ultrasound.
But if it's running straight towards us,
we typically don't see it as well.

Patient Positioning and Annotation

Next thing we're gonna talk about is patient
positioning and annotation.
Now in scanning the right breast, most areas
that we scan are in the upper outer quadrant of the breast.
So we're scanning the patient's right breast,
we'll roll them in an opposite posterior bike
or an LPO projection.
If I'm scanning the medial aspect of the breast, a lot
of times what I'll do is roll the patient supine
and if I'm scanning a patient, a large breasted patient
and looking at a lesion that is lateral,
sometimes I will roll them almost in a
decubitus position all the way.
And then what we're trying to do is thin the tissue planes
out as much as we can.
So having the patient bring their hand up
and behind their head is going to help thin the breast
and allows us to image much better
that even in fairly large breasted patients,
once we roll them
and raise their hand up over their head,
we're thinning the tissue planes out.
That rarely do we have to scan beyond about three
to four centimeters in depth.
Kind of a good rule to remember
that if you're using your high frequency linear array
transducer and you're trying
to image something at about five centimeters in depth,
you're pushing that transducer too far that you may need to
increase or go to a lower frequency transducer to be able
to see lesions better in the deep field.
Now as far as annotation, most lesions in the breast,
we use the clock face.
And then if you're scanning something
that is solid typically
or any type of lesion that we're going to do a follow up,
we will document centimeters from the nipple out.
If I am scanning a patient
and I see multiple lesions that are just simple cyst,
I will use the what I call the A, B, C one, two, three.
So looking at that, if we have a lesion that is close
to the nipple, we consider that area one in the breast
lesions that are midway out, we will label a area two
and of a lesions in the periphery.
We consider that to be three.
So in annotating, I will also label SA for subular.
If I'm scanning a lesion behind the nipple
and ax, anytime I'm scanning in the axilla
in typing this out, I will type right 12 o'clock.
Two, it tells me I'm in the right breast at the 12 o'clock
position halfway out in the breast.
Then what I wanna do is look at the depth.
If a lesion is very superficial, just under the skin,
we call that area A.
For lesions that are midway down in the
breast, that will be B.
And if a lesion is deep in the breast up against the chest
wall, we will label that area C.
So now in annotation
what I'll type in is right breast 12 o'clock to C
lets me know that at the 12 o'clock position,
halfway out against the chest wall is
where I will be able to see the lesion.
So just sort of in review, you can see the 1, 2, 3
and the A, b, C.
Just another example of scanning a patient
in the right breast at 12 o'clock
and the left breast at one 30, this would be the three B
because it's clear out in the periphery
and halfway down
through the breast this would be 12 o'clock, two
c halfway out and up against the chest wall.

Scan Planes for Breast Lesions

Now as far as scan planes,
pretty much everything in the body we scan in a standard
longitudinal and transverse scan plane.
When we look at breast cancer, breast cancer likes
to take the path of least resistance.
So if I scan this lesion in my standard longitudinal
and transverse, you can see
that the lesion looks fairly well circumscribed With breast
lesions, what we prefer
to do is scan it in a radial scan plane, very similar
to the spokes of a bicycle.
An anti radial is just rotating a transducer 90 degrees
to whatever the radial scan plane is.
This way we're able to pick up these subtle projections
of duct extension
or branch pattern that may be coming out within these
lesions that like to grow through the ductal system.
This is just a diagram of showing you scanning the right
breast at 10 30 a lesion at three B in a radial scan plane,
rotating the transducer 90 degrees
and scanning in an anti radial plane.

Normal Anatomy in Breast Ultrasound

Looking at normal anatomy with breast ultrasound,
the first structure that we're going
to scan will be the skin.
It will be just underneath the transducer face
and it should be echogenic about two
to three millimeters in thickness.
We then have the subcutaneous fat
that's seen just underneath the skin.
There's a pre fascial layer.
This fascial layer extends all the way up.
Wherever there's a cooper's ligament, it goes up,
attaches it the skin, and comes back down and continues on.
We then have the Cooper's Ligaments as I mentioned earlier,
that we can see extending
through the Fat Cooper's ligaments actually attach back at
the chest wall, extend all the way through the breast tissue
and up to the skin.
We then have the mammary zone
and we're fortunate this is where the majority
of breast cancers are going
to occur is in these structures here called A-T-D-L-U.
And on a lot of patients that's just about one
and a half centimeters in depth where our beam is focused,
the narrowest, we then have a retro mammary fascia
that we really don't see very well sono graphically.
There's a retro mammary zone of fat
and all the weight to the pectoralis muscle.
So when you first start imaging, you wanna make sure
that you can see all the way to the pectoralis muscle
that you're not cutting a lesion off if it is deep
against the chest wall.
So just showing you examples here we can see the skin
that is echogenic.
We have the pre memory fat,
we can see a Cooper's ligament extending up
and here is our memory zone down to the pectoralis
and then actually down to the lung through here.
Now looking at this pattern, I've heard some people refer
to this as ductal ectasia.
This actually is not ductal ectasia.
In fact, if you notice we have a small normal duct here
surrounded by per ductal stromal tissue.
So when you see this pattern that kind
of looks like Swiss cheese,
what we're seeing is actually the normal duct which is right
here in a short axis view.
This is rotating 90 degrees to the long axis view
of the normal duct and this is the loose per ductal stromal
tissue that surrounds the duct.
This is what allows ducks to expand
and contract during lactation.
And this is a pattern that you typically will see in women
in their thirties to early forties.
Typically before that they have more
of a glandular breast pattern, which is sort of gray.
And then the older women get the per ductal stromal tissue
tends to atrophy
and just sort of blends in
with the normal surrounding tissue.
So you typically will not see it after that.
What we will see with ductal ectasia, these images here uh,
are a normal completely collapsed duct.
Here's a duct with just a little bit of fluid
and a duct with a little bit more uh, uh, fluid within it.
We really don't get concerned about patients
with ductal ectasia unless they are symptomatic.
If they're presenting with abnormal nipple discharge,
then we will look in the decks for uh, papillomas and
and ductal lesions within there.
But 50%
of the women over age 50 will have some ductal ectasia.
So it's something we really don't get concerned about, uh,
if they are asymptomatic.

Normal Variations and Age Changes

We're gonna talk a little bit about normal variations
and age changes that we see when a patient uh, is scanned,
and this is sort of what a normal patient with a lot
of fibro glandular tissue will look like, you'll see
that there is the prem fat layer skin down into pectoralis
muscle and quite a bit of the fibro glandular tissue.
What we see with age is more
of the prem fat is increasing.
You can see the fibro glandular tissue we're not seeing
as much and if you notice,
we're seeing more retro mammary fat behind that mammary zone
to the pectoralis muscle.
But you can see Cooper's ligaments extending up quite
nicely in this fat.
As we progress on, you can see
that there is more fatty infiltration into
that pre mammary fascial layer.
We have a decrease in the amount of the mammary zone,
more retro mammary fat all the way down
to the pectoralis muscle.
And here we can see even more pre fat.
There's just a little bit of the fibro glandular tissue
that we can see down to the pectoralis muscle.
You can see um,
cooper's limbic ligaments extending up very nicely
up against that gray background of the fat that we're seeing
all the way into a completely fatty involuted breasts.
Where here we have the skin, here's kind
of the pre mammary fascial layer
and the entire mammary zone is filled in with fat
that we really don't see any fibro glandular tissue in this
completely fatty involuted breast.
So just sort of normal variations that we see
with age change
or hormonal changes from a normal breast to
where there's a little bit of fatty infiltration into more
and all the way into complete fatty evolution of the breast.

Mammographic Sonographic Correlation

Now looking at mammographic sonographic correlation,
there is one difference between breast sonography
and when we look at the mammographic algorithm
that is operator dependence, I've always said
that breast ultrasound
or any type of ultrasound is only as good
as the person holding the transducer.
When we look at mammograms
or mammography, obtaining the good images is
actually fairly easy.
There's a lot of excellent mammography technologists
that know all the right angles
and positions to put the patient in
to get these great mammographic views.
What is difficult is for the radiologist to interpret those
where with sonography it's just the opposite.
Getting a good view is what is difficult, knowing exactly
how much pressure, getting the right angle, making sure
that you're directly over the lesion,
that you're not creating something
once you get the good picture.
Making the diagnosis is fairly easy,
but being able to find the lesion
and get the good pictures of it on ultrasound is actually
what is more difficult.
When we look at mammographic sonographic correlation,
we compare our scan planes.
The transverse plane of ultrasound is basically the same as
what we're gonna see on the CC projection of the mammogram.
So I used to take patients film
and sort of hold it up underneath my own breast
and I would say, okay, my CC projection looks just like
what I'm gonna see on ultrasound.
If it's on the medial aspect, I know that that's
where I'm gonna be scanning is a
medial aspect of the breast.
On ultrasound, what is more difficult on comparing
mammograms to ultrasound is looking at the MLO view,
the OBL projections.
It's less predictable
because we don't know the degree of obliquity
that the MLO was projected at.
And so it becomes more difficult in figuring out exactly
where lesions may be.
In looking at that, when we look at the correlations
of mammography and sonography, lateral lesions appear
to be located more superiorly than they really are on the
MLO projection of the mammogram.
And the more peripherally that they lie,
the higher they're going to project on your MLO view.
Just the opposite is true for medial lesions.
They're going to appear
to be located more inferiorly than they really are in the
MLO and the more peripherally they are,
the lower that they will be.
You know, I've always had a hard time in remembering this
and how do I figure out which, which is which?
So the one way I remember it, muffins rise.
If you're on the medial aspect, you need
to look higher than a lesion really projects on the
mammogram and remember that lead sinks if you're lateral,
you need to look lower at lesions.
So it's kind of how I remember.
Medial lesions are going
to be scanned higher than they really
project lateral lesions.
You need to scan lower than they project.
So in breast sonography when we compare mammograms,
mammography, there's three densities that we deal with.
There's fat and fat is anything
that is gray on the mammogram.
Calcium, this is a benign calcification.
And the third density that we deal
with mammographically is called a water density.
A water density is anything that's white mammographically.
So in looking at this lesion here,
we have a mammographic lesion.
It is a water density
and this is where ultrasound is more most helpful
in looking at that
and determining exactly what we're dealing with.
What are all the things on a mammogram
that can make up a water density?
The most obvious is a cyst, also normal fibrous tissue
and normal glandular tissue.
And we can see the fibro glandular tissue through here.
Any solid nodule does not matter if it is benign
or malignant are water densities, mammographically
and then also your muscle and skin.
We can see a little bit of muscle here.
We know obviously this is not muscle or skin, but muscle
and skin are also water densities, mammographically.
So in looking at this patient that presents
with a palpable lump,
you can see there's a BB here in the left aspect
of the CC projection of her mammogram.
Is ultrasound going to be real helpful in this patient?
Not really. So since it was something palpable,
we went in and did the ultrasound.
You can see here's the skin,
here's the pre memory fascial layer,
here's a Cooper's ligament.
The entire mammary zone is completely filled in with fat
and expect to see something like this.
This is where mammography is the most sensitive in looking
at fatty involuted breast.
A lot of times when the patient has a palpable abnormality,
what they're feeling may be a Cooper's ligament
or maybe they just feel a fat lole.
But mammography will be the most sensitive in dealing
with fatty breast tissue
and you know you really don't need to spend a lot
of time looking for a lesion
because if it was there it would not be
missed on the mammogram.
Looking at mammographic sonographic correlation here we have
a very dense mammogram,
also a palpable lump in the left breast.
We scan this patient on ultrasound
and you can see here's the skin
and then the entire breast tissue is all just sort
of low level gray and you're like, well it looks like fat
but there's no way it can be fat
because we have a very dense mammogram.
We know that fat on mammography is going to be gray.
What this is is glandular tissue.
This is either a very young patient,
somebody in their teens, normally you wouldn't be doing
a mammogram on
or it is somebody who is lactating or pregnant.
So a lot of patients you can see why
mammography is not very sensitive.
In patients that are lactating, they have a lot
of glandular tissue
and glandular tissue on ultrasound tends
to be the gray tissue that we'll see.
Here's a patient with another mammogram that's very dense,
palpable lump on the right side.
And this is a patient that we see a lot
of fibro glandular tissue.
This is where ultrasound is the most sensitive in dealing
with patients with this fibro glandular tissue.
If you have an isoc coic lesion, it will jump out at you.
It's going to show up very well when we've got
that echogenic background to scan lesions on.
So this is where ultrasound is the most sensitive.
Now if the patient's had a mammogram, we want
to compare four things on the mammogram with
what we're looking at on ultrasound.
We wanna look at the size of the lesion, look at the shape
of it, figure out the location
and look at the surrounding tissue.
If the lesion that you're seeing on the mammogram is
surrounded by fat, then
what your skin on ultrasound should also
be surrounded by fat.
So the first thing is looking at the size.
When you're looking at the size of a lesion,
take into an account everything
that's a water density on the mammogram.
So I know that I'm going in to look
for a two centimeter lesion on the mammogram
and when I'm scanning all I can find is a one
centimeter cyst.
Well of that one centimeter cyst is surrounded
by a little island of fibrous tissue.
That may be why your size does not match up.
So typically what I would do in this case is measure the
cyst and then just take one more caliper
and measure across including the fibro glandular tissue.
But you can have a two centimeter cyst,
a two centimeter fibroadenoma, an area of fibrous tissue
or any lesion surrounded by fibrous tissue.
That may account for why we're looking
for a two centimeter lesion on the mammogram.
The other thing is when we look at the size
of a lesion, how do we measure?
We all know that if you're measuring A BPD,
it's leading edge to leading edge.
If you're measuring an aorta outside the
outside measuring common bile duct inside to inside.
But with breast ultrasound, a lot
of places people will just measure the inside
or the fluid of a cyst.
Some people measure on the outside and include the capsule.
The one thing that you wanna do is make sure everybody in
your department is measuring the same.
And in our department we do include the capsule on all
of our measurements If we're trying to correlate mammography
to sonography, the capsule is a water density.
But the biggest thing, make sure everybody in your
department is going to be measuring things the same.
Now looking at mammographic sonographic correlation, um,
here you can see that there's this area of uh,
lesion appears to be in the left lower portion
of the MLO view.
Go in and scan on ultrasound
and you can see that there is this area of fibrous tissue.
This is a pseudo mask created by fibrous tissue.
It's probably the most common question I get asked is people
will say they can see a view on a mammogram and they go
and scan on ultrasound and can't find anything.
Well remember take into account everything
that's a water density
and perfectly normal tissue can create a pseudo mass.
So what this patient needs
to do is have a spot compression view just to make sure
that the tissue smushes out.
Anytime we're calling something asymmetric tissue,
we do a split screen image.
You can see that on her right MLO view, there's this area
of fibrous tissue.
We have the same area
of fibrous tissue here on the right side
and this area of accessory fibrous tissue right there
creating a pseudo mass on the mammogram.
Looking at the shape of a lesion,
we will see a 90 degree rotational difference.
When we compare mammograms to ultrasound, think about
how a mammogram is done.
The breast tissue is pulled away from the chest wall
and compressed down With ultrasound,
we have the patient lying flat on their back
and then the normal weight
of the breast tissue is compressing the breast.
So looking at mammographic sonographic correlation
and looking at the shape lesions on the mammogram will
appear to be perpendicular
to the chest wall Mammographically.
When we scan the patient on ultrasound,
that same lesion will rotate 90 degrees
and now be parallel to the chest wall.
The other thing is looking at the shape
and location lesions on an ultrasound will always be closer
to the chest wall on ultrasound than they are
on mammography.
The breast tissues being pulled away from a mammogram
and being compressed down on ultrasound.
So here we can see there's a lesion.
It appears to be several centimeters from
the pectoralis muscle.
Once we scan the patient with ultrasound, we can see
that it's actually in denting into the pectoralis muscle.
So you'll always see more retro mammary fat mammographically
than you do sono graphically.
And that's just because our breast tissue on ultrasound is
being compressed down.
This is a patient on their mammogram, sort
of a conned in view.
You can see this area of fibro glandular tissue
and there's an area that peaks up here into the
super mammary fat.
If we look at this, this was an area
of architectural distortion.
There's nothing that should be peaking up into the fat
there Mammographically.
This is given a birads four classification.
Now anything that's a birads four
or five is typically recommended for a biopsy.
So we scan this patient on ultrasound
and it's always hard to get a single projection
of an ultrasound that shows
what you're seeing real time on ultrasound.
But in looking at this, we add this area of ductal ectasia
that extends up into the fat and comes back down.
If you notice, we have fat that's anterior same fat
that we can see anterior his is ridge a fibro glandular
tissue, same ridge, a fibro glandular tissue size, shape,
location surrounding tissue all match up.
We've taken what had been given a Birads four
mammographically and turn
that into a BIRADS two one ultrasound
and basically this patient does not need any
further follow up.
This is the one I think all sonographers absolutely hate.
You can see this one little mammographic that will do,
it's in both projections.
You can see it on the MLO and the CC view.
And this happens to be the patient
that had her mammograms done on a 14 by 17 film
and basically you get the short straw.
So you start scanning, looking all over,
you know it's in the upper outer quadrant of
that right breast and you can't find anything.
If you can't find it, most likely you're dealing
with a solid lesion.
So what can be helpful is to look for the capsule
that surrounds it.
But another thing that I've learned
that can be very helpful, if we think back
to our anatomy 1 0 1 classes, what are the three structures
that run through the breast
or actually through the body together's, your lymphatics,
your blood vessels and your nerves.
In fact, you can see there's this little lymph node here
and here we have this blood vessel adjacent to it.
So one thing I've learned is if you turn on color doppler,
find a blood vessel in the upper outer quadrant
of the breast, sort of start up near the axilla
scan down into the breast.
And with that color doppler turned on, a lot
of times those blood vessels may lead you right
to these small inter lymph nodes that are very difficult
for us to see because they are iso co
to the surrounding tissue.
If you can't find it with ultrasound, then what we typically
recommend is that the patient gets a six month single
projection mammogram follow up, not another ultrasound
or you'll drive all your sonographers crazy

System Optimization

system optimization.
Now when I talk about a lesion being iso coic,
what am I referring to?
You know, early literature compared everything in the breast
to fibrous tissue.
Well, fibrous tissue on ultrasound is this bright
white stuff that we'll see.
So if I compared everything to fibrous tissue,
everything would be hypo coic to that.
One thing that we wanna do is find something
that every patient will have
and something that we can call about on the 50 yard line.
And that one thing is fat.
So we call compare everything in the breast to fat.
If I say a lesion is echogenic,
it's brighter than fat evol lesion is iso coic.
It's equal to fat and evol lesion is hypo coic.
It's darker than fat.
If you're only going to listen
to one thing about this whole lecture, this is the one thing
to make sure that you have always set fat at medium gray.
Make sure that when you optimize your machine you find an
area where there's fat and you turn it so
that fat is medium gray all the way from skin line down
to the pectoralis muscle.
Here we have an example. You can see what looks like a cyst.
Nice good borders, nice through transmission,
but one problem, what color is fat?
Fat set is black.
So once I turn my fat back so that it's medium gray,
is this truly a cyst?
We can see all these internal echoes
and once I actually show you a different projection,
this is rotating my transducer 90 degrees.
There are obvious malignant features within this lesion.
This one image here was a cut taken right
through this portion of the lesion.
But what we're seeing, this is a high grade
invasive ductal carcinoma.
Just because there's enhanced
through transmission does not mean
that you're dealing with a cyst.
Your high grade cancers has as much enhanced
through transmission as a cyst does.
So yes, shadowing is something worrisome for malignancy,
but just because you see enhancement that is not reassuring
that you're dealing with a benign lesion.

Palpable Nodules

Next we're gonna talk about palpable nodules.
Now with palpable nodules,
remember our number one goal in ultrasound is to try
and prevent an unnecessary biopsy.
If we can show that
what the patient is feeling is a simple cyst,
a fibro pseudo mass, a complex cyst
or a fibro adenoma,
we can avoid having the patient have a biopsy.
So looking at these lesions,
if the indication is something palpable, even
before you start scanning, make sure you feel the lesion.
It's gonna tell you a lot about what you're looking for.
If it feels like it's a bb, you know it's going
to be very superficial.
So you need to worry about your elevation plane focus using
a standoff pad
or extra gel to get that closer to the standoff.
The next thing is, while you're scanning,
make sure you take your finger
and run it underneath the transducer.
Make sure that what you're seeing
and what the patient feels is the exact same thing.
The number one palpable lump is a ridge
of normal fibro glandular tissue.
This is more common than a cyst or anything.
Now any patient who comes in your department
for an ultrasound because they feel a palpable lump
in their mind, they just know
that they've got breast cancer.
So if you're allowed to talk to your patients
and let them know that
what they're feeling is normal tissue,
you're gonna make their life
or their life much easier that day.
'cause in their minds they think they've got breast cancer.
One thing you wanna make sure that if they're going
to follow normal fibro glandular tissue, they check
that area once a month
and if anything changes
that they definitely have it reevaluated.
Now looking at cyst, the cysts that patients come in with
that are palpable are tension cysts.
They're the cysts that are under pressure.
These other cysts, I call these lazy cysts.
These can be big, huge cysts,
but they're not under pressure.
Rarely are these palpable.
In fact, next time you have a patient that you see one
of these in, take your finger, run it over it,
see if you can even feel it.
But it's just sort of feels like normal tissue.
These tension cysts can only be a couple centimeters in
or a couple millimeters actually in size,
but they're very palpable 'cause they're under pressure.
A lot of times on the lazy cyst,
what you may be feeling is more
of the fibro glandular tissue that extends up over it.
So here's a patient that came in
with a palpable lump sonographer was great.
She did all the palpating felt
where the lesion was put the transducer down,
boom, there's a cyst.
But what kind of cyst is that?
It really isn't a tension cyst.
By going back in and doing simultaneous palpation
and scanning, what she was feeling was this iso
coic fibroadenoma.
Now cysts are so common just
because you see a cyst in the same area as a palpable lump,
don't assume that that is what the patient is feeling.
Make sure you do the simultaneous palpation and scanning.
Standoff pads are something
that we use quite often if we're dealing with lesions
that are too close to the skin.
If we need to move something closer
to the elevation plane focus.
Now for any of you who've been doing ultrasound
for quite a few years, you're going
to remember those three centimeter standoff pads
that we used to use for general imaging.
You wanna make sure that you're not using a standoff pad
that's three centimeters thick
or your beam will be focused right in the middle of it.
Typically, you want to use a standoff pad
that's a centimeter in thickness or so.
But what's the problem with standoff pads?
Once you get them placed on the breast,
and if the indication was a palpable lump,
you're no longer able to palpate the area
that the patient was feeling.
I don't know about you, but for me, I always seem
to get air bubbles trapped under there.
So you're scanning along
and all of a sudden you run into an air bubble
and you can't see anything behind it.
But the thing I really hate is when you're scanning,
you're looking at your ultrasound screen
and you figure out what on earth am I seeing here?
You look down at the patient
and the standoff pad has now slid
all the way up to her thyroid.
Instead of doing a breast ultrasound,
you're scanning her thyroid.
So instead of using standoff pads, what I prefer
to do is just use a big glop of gel.
And the problem with using a big glop
of gel is when you put your transducer down,
all the gel smooshes out.
So you end up by squeezing another big glop of gel.
I'll show you a trick that you can use if you take your
little finger and put it
underneath the edge of the transducer.
When you put the transducer down,
you now have a built-in standoff pad.
It makes it great. You're not having to use all
that gel just for scanning one little area
and you don't have any air bubbles
that get trapped under there.
This is called the wrap technique.
Looking at the near field volume averaging,
this is a patient that presented with a palpable abnormality
and you're like, where is there even anything palpable?
But several things wrong with this image.
You can see this is kind of the area
that the patient was feeling.
The lump, this is one centimeter right across here.
So we're scanning something within the
first five millimeters.
And the other thing, remember when I first talked about
focal zones, somebody forgot to move their focal zones up
to optimize this image.
So once we use a standoff pad of gel,
we move our focal zones up.
You can see that we actually have a small cancer sitting
right here underneath the skin
that could not really even be seen here without
optimizing our image.
So remember elevation plane focus, wheres the beam?
Focus the narrowest and be sure
and keep your focal zones moved.
To where the area of interest is that you're looking at

Split Screen Imaging

split screen imaging.
This is when we're comparing right side to left side.
So with mammography, what we're looking for a lot
of times is any asymmetric tissue density.
And on ultrasound, if there's asymmetric tissue density,
we wanna do mirror image,
split screen images comparing the right to the left side.
So here on this mammogram you can see
that there's water density in the right
axillary segment of the breast.
When we compare it to the left,
there's just normal fat on that side.
So on ultrasound we go into split screen.
You can see that we've got normal fibro glandular tissue
that corresponds nicely to
what we're seeing on the mammogram.
We've got fat in the left axillary segment
that compares nicely to what we're seeing there.
So one ultrasound image can show you the asymmetric tissue
density, same as to
what we're seeing on the patient's mammogram.
We'll also do split screen imaging
to check the compressibility of lesions.
If we're gonna call something a lipoma, we like
to see it compressed 30%.
Fibro adenomas may compress somewhat but rarely over 25%.
And some of your cancer, especially the highly
cellular ones, may compress but rarely over 15%.
So this is a patient presented with a palpable lump.
Looks like it's a lipoma.
But one more thing we like to do just to prove is
to check the compressibility.
So we'll go into a split screen image,
the first image we take with very light pressure,
lighten up, add extra gel, lighten up your pressure
so you're barely making contact with the skin
on your next image.
Switch to the other side, compress down.
And we like to see at least a 30% compression
in looking at these lipomas.
Now sometimes you'll have lipomas that are more echogenic.
Those will not compress the 30%, the ones
that we see 30% compression.
Are the iso coic lipomas looking at this lesion.
Is this a fibroadenoma or could this be a trapped fat lo?
Now one thing you'll notice on fibro adenomas will allow
three gentle loation.
This has more than three gentle loation.
So this would be given at least a birads foray.
I'll show you three maneuvers that you can do to try
and prove if you possibly could be dealing
with a fat lole versus a fibro adenoma.
First thing check compressibility, does it compress 30%?
Now just the normal weight of breast tissue.
If you're dealing with fat that's deep in the breast,
you may not get the 30% compression
that you will on more superficial lesions.
The other thing is just take your transducer
and start rotating it around.
See if it hooks up to the retro or super mammary fat.
And the third thing is look for the straight white line.
Anywhere that I have compressed,
you can see this white line.
Now if you lighten up your pressure,
the light white line will go away,
compress down, it'll come back.
What this is, if you've ever seen fat fat's,
not just a sheet in there, it's one glob
of fat up against another.
So what we're doing is catching the interface
of one fat lole against the other one.
If you lighten your pressure,
the interface runs up at an angle so
that we're not seeing it.
But as you compress down one interface to the other,
you are now scanning that at 90 degrees.
So you're able to see the interface from one
fat lobule to the other.
Beware fi adenomas may have echogenic lines on MRI,
they're called the sapphire sign,
but they tend to be more on the periphery.
And also any lesion that would've had a previous biopsy,
you might see the scar through that,
but that will be there no matter whether you scan
with light pressure or heavy pressure
with these fat interfaces.
As you lighten your pressure,
you're gonna notice the white line goes away.
And then as you compress, you'll notice that you see it.
More variable compression with 2D imaging
will also do split screen fiber.
Adenomas can be in a rotation
that they possibly could be in a non-parallel access
or a taller than wide.
But cancer, if it's in a taller than white access, no matter
how hard you push, you cannot get it to rotate.
This was a patient that presented
with a palpable lump in scanning
with normal to light pressure.
You can see what looks like a fibro adenoma,
but it is in a non-parallel presentation
or same as taller than wide.
And that is a feature worrisome for malignancy.
If we compressed, we could actually change the orientation
of this and make it parallel to the skin.
This particular patient elected to not have a biopsy.
We followed her for three years out
and this never did change in size.
The other thing that can happen is if you scan
with too light of pressure,
you can actually get shadowing from a Cooper's ligament.
The Cooper's ligaments may be running up towards us,
but by compressing you can flatten those out here scanning
with very light pressure.
This looks like a fibroadenoma,
but we have shadowing behind it.
Shadowing remember is a feature worrisome for malignancy.
But by compressing we were able to make
that shadowing go away.
This was just an artifact on the shadowing
and compression can make it go away.
I would say about once a year we would get a patient
that would present with a palpable lump.
You can see that her palpable lump is a simple
tension cyst right here.
And on her mammogram.
Nothing showed up else in the breast,
but you can see this area,
small breast cancer sitting right next to the cyst
with intense shadowing behind it.
Now with breast ultrasound, a lot
of times we become very tunnel vision.
We see these really small cysts in there.
We're trying to clean them out.
We're trying to show the through transmission
and good posterior borders and enhancement.
And we become so tunnel vision that we take a picture
that looks something like this.
This looks just like the cancer I showed you sitting
next to the cyst.
If this patient has films that are red, at the end
of the day, she's gonna be recommended for a biopsy.
But this was just created by scanning
with two light of pressure.
Once we went back over the same area compressed down,
we can completely make that go away.
So it was an artifact
of just the normal fibro glandular tissue with scanning
with two light of pressure.
Now one of these is the cancer and one is not.
And usually I'll ask people who thinks this is a cancer
and who thinks this one is, but nobody guesses anyway.
But my main point is just to show you
that you can take perfectly normal tissue
and make it look just like a lesion.
And all I did was lighten up my scan plane.
If you scan with too light of pressure,
you can take perfectly normal tissue
and make it look like there's a lesion there.
So ultrasound requires variable scanning pressure.
If you're scanning looking for the presence of blood flow
or color doppler, you need to scan with very light pressure.
If you're getting what looks like shadowing, you need
to compress and make sure that it's not artifactual.
But variable compression is what's
necessary for breast imaging.

Imaging the Nipple

The last thing I'm gonna talk about is imaging the nipple.
A lot of times people think
that on ultrasound we really cannot image the nipple.
One reason is if we look at the ducks
and how they run, they run straight up towards us.
If we're scanning in an AP projection of the nipple.
Now anything that's running straight up towards us is going
to create an artifactual shadowing.
So we need to come up with a maneuver
or something that we can do to be able to
evaluate actually within the nipple.
And the way that we've done this is a couple
different approaches.
Now, if we're scanning the nipple in a straight
AP anterior projection,
you can notice we have intense shadowing behind the nipple.
This patient had presented with bloody nipple discharge
and we can see that there is some ductal ectasia here,
but we really can't see anything else
going on within this patient.
So one thing we can do is just called
peripheral compression.
If we take the transducer
and just sort of roll the nipple onto its side, you can see
that we're able to scan more of that ductile system.
But we still are getting some shadowing coming out from the
ducts 'cause we just don't have the right angle that we need
to image that we can do a two-handed compression.
So what I will do is take my free hand,
push up on the breast, take the transducer,
and push up on the other side.
And what we're able to do is see more through
that ductal system,
but we still are getting some shadowing coming in.
So the way that we can image directly
through the nipple is if we do what's called a
rolled nipple technique.
So we take our free hand, take the index finger,
lay it up against the nipple, take the transducer,
and compress the nipple over our finger.
Then what we're able to do is scan the entire
nipple all the way through.
So this is my index finger here.
This is the patient's nipple.
You can see that we're able
to see the duct all the way into the nipple,
and then we would line it up with the additional views
that we had with the two handed compression
and peripheral compression to evaluate the rest
of the ductal system.
But in doing these different maneuvers, we are able
to evaluate the nipple with ultrasound
and not get intense shadowing behind it.

Conclusion

So once you all understand breast
sonography, you'll love it.
Have a great day.