Advanced Breast Ultrasound

Introduction

Hi, I am Cindy Rapp.
I'm a sonographer from Denver, Colorado
and today I am gonna be talking about
advanced breast ultrasound.
We're gonna cover intraductal lesions
and sonography of implants.
We're gonna be talking about advanced
breast ultrasound today.
Particularly looking at intraductal lesions
and sonography of implants.

Breast Anatomy

Looking at breast anatomy, basically there's 15
to 20 lobes within the breast.
These are a varying size of ducts and lobules.
They're surrounded by connective tissue
and each lobule has approximately 30 ductules
or acini in each of them.
The ducts of the breast can be very tortuous.
Later on in this lecture I'll show you some different
maneuvers that can be done to help
straighten out the tortuosity of the ducts
that we run into in breast ultrasound imaging.

Evaluation of Nipple Discharge

Evaluation of nipple discharge mammography is seldom helpful
in evaluating nipple discharge.
Galactography is considered the gold standard,
the role of ultrasound is still expanding
and we are going to define it a little bit better today.
When we image patients for nipple discharge,
galactography typically is reserved for our high risk patients.
High risk patients are those that are considered to have
spontaneous expression of the secretions,
typically only from one side coming from a
single duct orifice.
The discharge color should either be clear, serous, serosanguineous or bloody More low risk that we tend
to use ultrasound for is when the secretions are expressible
only if they are bilateral,
if they come from multiple duct orifices
or if the discharge is greenish or milky.
In looking at these different discharges
that can come from the nipple here is
what the clear would typically appear to be serous,
serosanguineous and frankly bloody type discharge.
The low risk type ones that we will see are
as if they're greenish or an actual milky discharge
and other types that occasionally can occur.
More of an indeterminate is when we get this CTO
or more of a cheesy type of appearance
of the nipple discharge.

Use of Ultrasound in Nipple Discharge Evaluation

Now the use of ultrasound when we evaluate patients
with nipple discharge, if galactography is suboptimal
or if it fails,
sometimes you could actually get a keratin plug
that obstructs the duct
and so you cannot get any nipple discharge.
Occasionally you can have unsuccessful
cannulation of the duct.
Extravasation of contrast behind the nipple can possibly occur.
The duct can be so large
or filled with so much contrast
that it will actually obscure the lesion
and I'm sure none of you have ever
cannulated the wrong duct.
But occasionally the wrong duct can actually be cannulated
when evaluated patients with ductal ectasia.
So here's an example of when a galactogram had failure.
You can see that there is extravasation
of the contrast within this duct.
So we went ahead and did ultrasound.
Patient had presented with bloody nipple discharge
and what we can see is a little bit
of ductal ectasia here in this intraductal papillary lesion.
So ultrasound was able to definitely give us the answer
that we needed in evaluating this patient
with nipple discharge.
Here's another example of a patient with a galactogram
that we had a failure of.
There was just too much contrast,
it was too dense with ultrasound.
In evaluating this patient, you can see
that there are multiple ducts with fluid in them
and you can see that we've got papillomas
in multiple locations.
So ultrasound once again was very helpful in evaluating this
patient that presented with abnormal nipple discharge.
This is a patient when doing the galactogram,
everything was perfectly normal.
So we went ahead and took a look with ultrasound
and actually found there was a separate duct
that there was ductal ectasia
and an intraductal papillary lesion
was seen within that duct.
So ultrasound was very helpful in evaluating the patient
where the wrong duct was cannulated.

Characteristics of Intraductal Papillomas

Now a lot of people think that intraductal papillomas
are echogenic, they really are not echogenic.
If you do see something
that you believe is an intraductal papillary lesion
and it is echogenic
or the same echogenicity as the fibroglandular tissue,
actually what you're getting is just an area
where the duct courses off to the side
and this is a pseudomass.
You can see when we rotate 90 degrees,
what we're picking up is just this band
of fibrous tissue sitting between these two different ducts.
Here, actual intraductal papillomas are not echogenic,
they are hypoechoic.
In other words, they are the same echogenicity as fat.
If you notice the normal wall of the duct
that we can see right along here is echogenic
and intraductal papillomas tend to be more hypoechoic
or same echogenicity as the surrounding fat.
So this is looking at a long axis view of a duct
with ductal ectasia
and intraductal papilloma rotating 90 degrees
and getting a short axis view of also
that same intraductal papillary lesion.
Just showing you another example, here's a patient
with a fairly long intraductal papillary lesion.
You can see the wall of the duct is echogenic
and the papilloma itself is hypoechoic.
This is long axis view.
Here is also a short axis view showing you the echogenic
wall and the hypoechoic papilloma.
Now often ultrasound can show you the extent
of the lesion better than the galactogram does.
Here you can see, we can see a filling defect on galactography
looking on ultrasound,
we can actually see this very long
intraductal papillary lesion.
So we can often see the extent of the lesion better
with sonography than we do galactography.

Imaging Techniques for Ducts

Now what we wanna make sure when we're imaging patients
with nipple discharge, we wanna make sure
that we see the entire duct to the orifice on the nipple.
When we scan, we wanna try and keep a warm room
and having warm ultrasound equipment,
usually this is not that hard to do.
They put out quite a few BTUs use warm gel
and then we scan in a radial and antiradial scan plane.
We talked about special maneuvers that we can do to be able
to see the ducts better and we will cover those.
In doing these special maneuvers, we're able
to visualize the ducts that are subareolar
and even ducts that can lie within
or lesions that can lie within the nipple.
We can see those much better in doing these maneuvers.
Now what happens when we image the nipple itself,
if we look at the way the ducts run in the nipple,
we get sort of a 90 degree angle between the ultrasound beam
and the segment of the ducts.
Different maneuvers that we can do.
We can do a peripheral compression, we'll go over each
of these individually two handed compression
and also a rolled nipple technique.
And typically we will use that
for evaluating the actual ducts inside of the nipple.
So in looking at this diagram of the nipple,
you can see one reason that if you scan straight over the
nipple you get intense shadowing.
All of the ducts are actually running straight up towards
the ultrasound beam.
On ultrasound, we see structures that are parallel
to the transducer face much better than we do ones
that are perpendicular to it.
So if we scan directly over the nipple, majority
of time we get intense shadowing
and cannot see anything retroareolar.
So we'll cover these different maneuvers that can be done.
So this is scanning a straight anterior posterior approach.
This is a patient that presented
with abnormal nipple discharge.
You can see that there is some ductal ectasia here,
but we just get intense shadowing
behind the nipple when we do scan in a straight anterior
posterior approach.
Now doing a peripheral compression,
what we do is take the transducer
and just sort of push on the side of the nipple,
lay the nipple down.
You can see we're seeing a little bit more
of the ductal ectasia,
but we actually are still getting shadowing directly
behind the nipple.
Now doing a two-handed compression, this is one technique
that I use quite a bit just to straighten out the ducts.
When you're evaluating them,
I'll take my free hand, push it up on the edge
of the breast, take the transducer on the opposite side
of the breast and just sort of compress.
And then you scan around the breast that way.
So if you're pushing from the three o'clock side,
your transducer will be on the nine o'clock side.
If you're pushing from the 12 o'clock side,
your transducer will be at the six o'clock side.
Just sort of work your way around the breast looking
for ductal ectasia.
Once you find an ectatic duct, then we're looking
for the lesion that possibly could be within
that ductal system.
The rolled nipple technique is what is very helpful
for evaluating the ducts actually inside of the nipple
what you do is you take your index finger,
lay it right up on the side of the patient's nipple,
take your transducer, sort
of roll the nipple up over your finger.
In fact, on this image here, this is my index finger,
this is the patient's nipple
and then you can see a normal duct extending all the way
through to the very edge of the nipple.
One thing that you need to make sure you do is use a lot
of gel for evaluating the nipple just to make sure
that you don't get any air artifacts when
you do this type of scanning.
Now here's a patient. When we scan directly over the nipple,
you can see we've got a big gel standoff here.
There's a scanning sort
of straight AP on the nipple in an anterior view
and we're questioning if there is a papillary lesion
within the nipple.
But you can see by doing a rolled nipple technique,
here's my index finger located right in this area.
This is scanning directly up over the nipple.
You can see the ductal ectasia coming all the way down.
There is one intraductal papillary lesion here
and a fairly long lesion extending all the way through here.
So we can actually see the papilloma within the nipple
and this very long one
by doing this rolled nipple technique.
Here's a patient that we scanned.
You can see this is scanning directly through the nipple.
We can definitely see that there is one intraductal
papillary lesion in this area.
And we had a question as
to whether there was a second lesion right in this area.
Now remember I did tell you
that intraductal papillomas are not echogenic,
they are hypoechoic.
But in doing the rolled nipple technique, what we were able
to see is this is only a single lesion here.
This is one ectatic duct,
another tight duct sitting right here.
And actually what we were seeing was the space
or the wall between those two ectatic ducts
and it was not a second intraductal papillary lesion.
There was only one.
We can also look and see the extent
of the papilloma into the nipple.
You can see in doing the rolled nipple technique,
we can see the papilloma right here.
This is scanning straight AP.
You can just see that we're not able to visualize very well.
And then just sort of doing a elongated image
through here, we can see the extent of
that papillary lesion throughout the nipple.
This was another patient that presented
with bloody nipple discharge.
We scanned completely around,
did not really see much ductal ectasia, but then went ahead
and did the rolled nipple technique.
And we can see what the patient has is a true papilloma
lying just in the nipple only.
There was no other ductal ectasia she had presented
with bloody nipple discharge.
But here you can see the long axis view
index finger through here.
This is the entire nipple, the ductal ectasia, the papilloma
and then rotating 90 degrees
and getting a short axis view of the papilloma
inside of the nipple.

Differentiating Secretions from Papillary Lesions

Sometimes you may have echogenic secretions that can sort
of mimic intraductal papillary lesions.
So this is just thick secretions within here,
whereas this is a true sort of more
of a papillary lesion that we can see.
Now one thing that can be helpful if you do have a patient
that has thick secretions, you can actually do some augmentation.
So if you take your transducer
and compress down you'll be able to see the fluid sort
of moving back and forth.
So very helpful in evaluating that.
If we look at this patient here,
we have a fluid debris level
and we were questioning
that versus looking at a true intraductal papilloma,
the fluid debris level,
you typically have a straight line going across,
whereas a true papillary lesion, you can see it's sort
of rounded on the ends.
Now what's very helpful to evaluate these is
by doing the augmentation maneuver.
So compressing down, releasing your pressure
and you'll be able to see the fluid move back and forth.
So you can see sort of elongation of this.
This was just thick secretions that we can see within
that patient with ductal ectasia.
In looking at that and the secretions were mobile
when we did the augmentation, you can turn color doppler on
and as you compress down you can get the fluid
to move one direction
and when you move the other way you can see
that the fluid comes back.
So this was actually with compression
fluid moved down the duct.
As we release the pressure,
the fluid came back up through the duct.
So it's something
that we actually typically will just watch in real time
and don't often use color doppler.
But you can see the secretions moving back
and forth as you are doing your
compression color.
Doppler can also be very helpful to
evaluate a fibrovascular stalk.
Papillomas tend to have quite a bit of flow within them
and typically a normal single vessel feeding them.
So here is a short axis view
that we can see this fat fibrovascular stalk
feeding the papilloma.
If you notice there is some ductal ectasia here,
but this is just some thick secretions.
There was no flow located in
that area on that particular patient.
Now looking at inspissated echogenic secretions versus a
papilloma, if you use light pressure sometimes you can see
that there is sort of fluid moving back
and forth with the echogenic secretions, whereas
with the true papillary lesion we get a vessel cord
coursing through the middle of it.
So this is an intraductal papilloma,
this was just thick secretions
and by applying pressure you can sort
of get the color swoosh that you can see with that.
Now one thing to be aware of, papilloma can undergo
hemorrhagic infarction
and so sometimes you may not see doppler flow
if they have infarcted.
If you try your augmentation
and you don't see the fluid moving back and forth
and it sort of is a thick structure
but you don't pick up any flow,
it possibly could be an infarction of the vascular stalk of that papilloma.

Multiple Papillomas

Now multiple central papillomas are more commonly seen sonographically than they are on galactogram.
And here we can see different ducts
that we can see the papillomas in.
So ultrasound, it's fairly easy
to pick up when a patient does have ductal ectasia
and imaging in multiple planes.
We can pick up these multiple papillomas in there.
If they happen to lie in a different ductal system
that was not cannulated for the ductogram, you can see
how those could easily be missed on the galactogram,
this is also showing you these multiple papillomas
and the fibrovascular stalks that we can see within them.
So once again, color doppler can be very helpful
for picking these up if we do detect the
fibrovascular stalk.

Scanning Approach for Nipple Discharge

Now, when I start to scan a patient that comes in
with abnormal nipple discharge as a sonographer,
I typically do not have them express any of the secretions
when I start my imaging.
If I have them express the secretions
and then the radiologist comes in to try
and do the galactogram,
sometimes all the secretions have already been expressed
from doing the ultrasound.
So I tend to have them wait
to expressing the secretions when they're
gonna do the galactogram.
But what I'll do is ask them if they know what portion
of the nipple that the secretions typically come out of.
If it's at the 12 o'clock,
three o'clock, six or nine o'clock.
And if they can't really tell, then I sort of scan
with my transducer in a radial scan plane
with it halfway on the nipple
and sort of in the soft tissue surrounding it.
And then just sort of work my way around looking
for ductal ectasia.
Once I find an ectatic duct, I will just sort of sweep
that area back and forth and longitudinal.
Then I rotate my transducer 90 degrees to sort
of the antiradial or radial scan plane
and evaluate it that way.
And then just continue looking all the way around
for any more ducts
that might have ductal ectasia within them.

Factors Affecting Appearance of Intraductal Papillary Lesions

Now there's several different factors affecting the
appearance that we will see
of intraductal papillary lesions.
With ultrasound, you may have presence of ductal dilatation.
So if you look at these, it's fairly easy
to see the papilloma.
If there is ductal dilatation.
Sometimes you may have the papilloma just obstructing the
proximal portion of the duct.
You may have it branching into multiple ducts.
You can have very large papillomas extending the entire
length and even branching into it.
Sometimes you may have them forming into branching ducts,
you can have them in a cyst
and then you can have cases
where it actually doesn't even involve any ductal ectasia,
but you may see a little bit of duct extension
or branch pattern coming off of these different papillomas.
But many appearances that we can see sonographically
of these intraductal papillary lesions.
So the spectrum of appearances that we'll see
with these large duct papillomas.
Here's just example of a small oval nodule
that we can see duct ectasia both proximal and distal to it.
Here's a small oval nodule that we can see.
There's only duct ectasia proximal to the lesion.
This is a fairly long papilloma extending into two different
branches of the ducts.
This is a long papilloma
that just fills the entire central duct.
It's not branching. And here's just another very large one
that is branching also into multiple
ducts of that papilloma.
Now these are all papillomas without duct ectasia.
Here is one that can just be presented sort of
as round or oval.
This is one that is microlobulated.
This is a papilloma that we can see just an area
of duct extension.
This is another intraductal papillary lesion
that we can see a branch pattern coming off.
And then sometimes we can get a lazy Y appearance
of the nodule with ductal extension into that
or the branch pattern that can be seen.
This is looking at isolated sort
of just minimal duct extension
or ductal ectasia not coming from the nipple,
but here you can see the papilloma within it.
We may see intracystic papillary lesions
and intracystic papillary lesions
where it actually extends into the duct
and then also into the cyst.
So these are all sonographic
or different sonographic appearances that we can see
with these intraductal papillary lesions.
The diameter of the intraductal papillary lesion does affect
its ultrasound appearance.
You can see here's a very large ectatic duct
and a fairly small intraductal papillary lesion.
These are ones that fill the lumen but do not expand it.
And here's a very large intraductal papillary lesion
that actually expands the size of the duct.
So these are all different sonographic appearances
that we can see.
Intraductal papillary lesions tend
to have a very high water content
and so what we typically will see with a lot
of these is enhanced sound
or through transmission
behind these large papillary lesions just
because the amount of water content
that they have within them.
Intraductal papillary lesions are also fairly soft.
So if you scan with heavy pressure, a lot
of times you can compress them.
Beware though, if you're looking for the presence
of a fibrovascular stalk, you need to make sure you scan
with fairly light pressure
because compressing them,
you may actually temporarily ablate the flow
and not be able to pick up your doppler signal.

Etiologies of Nipple Discharge

Now there are several etiologies for nipple discharge.
You could have a benign intraductal papilloma,
there could be carcinoma or DCIS
or invasive DCIS may have atypical ductal hyperplasia.
You may have just some ductal ectasia,
possibly a communicating cyst
and sometimes it's just idiopathic.
We can't really tell why the patient presents
with nipple discharge, but this is a patient that came in.
You can see on the right side there's just a
normal small duct here.
She presented with nipple discharge
and all we could see is just ductal ectasia
that was causing this patient's nipple
discharge on the left side.

Duct Ectasia

Now duct ectasia that causes nipple discharge.
There can be different echogenicity of the secretions.
Sometimes they may present as almost anechoic.
They may have some low level echoes within them
and sometimes they may be fairly echogenic.
But just to make sure
that these are not true papillary lesions
or intraductal papillary lesions,
doing your augmentation is very helpful in actually seeing this
fluid swoosh back and forth.
Both anytime you see any type
of low level echoes within those papillary
or intraductal lesions.

Hyperprolactinemia and Periductal Mastitis

Now when we have a patient that presents
with chronic nipple discharge
and you see severe bilateral ductal ectasia, we need
to think of hyperprolactinemia,
but this is scanning retroareolar on the right side
and the left side and you can just see
that there is chronic ductal ectasia.
There's low level echoes within it
and this was a patient that did have hyperprolactinemia
now ductal ectasia that causes nipple discharge.
Sometimes a patient may have a little bit of pain
and have some acute periductal mastitis.
The normal walls of a duct are thin and echogenic.
But when a patient gets inflammation of the duct,
you can actually see the walls become thick
and hypoechoic, this is the same sonographic appearance
that we see in cyst.
A normal cyst wall is thin and echogenic
and when a cyst becomes inflamed, the walls become thick
and hypoechoic color Doppler can also be helpful in evaluating
the patient with acute periductal mastitis.
But here's a patient that was having
bloody nipple discharge.
You can see all this echogenic secretions.
This was all hemorrhage inside
of the duct putting on color doppler.
You can see the hyperemia
that we can see within this in a long axis view,
rotating 90 degrees, you can see the short axis view of
that hyperemia within this patient having periductal mastitis.
Just another short axis view, looking at the bleeding duct,
if you notice there's a normal duct sitting adjacent to it.
Notice there's no hyperemia within this duct.
This is the duct that has the periductal mastitis
and you can just see the amount of
hyperemia within that duct wall.
And on galactogram,
once again you can see the same area on the ductogram
showing you that periductal mastitis.
Now when we use color doppler, there's one way
to tell the difference between infection
and a true papillary lesion.
Hyperemia will be in the wall, so it's gonna be more on the
outside or parallel to the duct wall.
Whereas if you have a true intraductal papillary lesion,
the flow is gonna be located central
so it's gonna be perpendicular to the duct wall.
So this is just an intraductal papilloma
and you can see the blood vessels
coursing right through the center.
Whereas when we have an inflammation,
it's gonna be more in the wall
and parallel to that duct wall

Communicating Cysts

Communicating cyst can cause nipple discharge.
This is sort of a trigger point.
You have to be careful because if you take your transducer
and compress down on either of these communicating cysts,
you may actually get quite a bit of ductal ectasia or
nipple secretions to express directly
through that area there.
This is another patient
that we can see communicating cysts causing nipple
discharge, sort of the trigger point
as we compress on the cyst, you can see that we got the flow
to move one direction.
When we released the compression, we actually saw
that the flow came back.
So that's just using color doppler to show
that trigger point on it.
These are also communicating cysts causing nipple discharge.
You can see all of this ductal dilatation,
all these different cysts
that actually communicate with that duct.
And thus this was present in a patient that did present
with nipple discharge.

Ultrasound-Guided Procedures

Now ultrasound guided percutaneous ductography, if you cannot
cannulate the duct when the patient comes in,
you can use ultrasound to actually put a needle in here
and do the ductogram.
If there is a failure, you cannot cannulate the duct.
So ultrasound can be very helpful if ultrasound can be used.
If you cannot cannulate the duct, you can take a needle
and apply it right here into the duct, fill it
with the fluid and then be able
to evaluate the duct ectasia fairly well.
If you do have failure of cannulation of that duct.
And here's just the example,
you can see the needle coming in directly into the duct.
So ultrasound guidance can be very helpful
if you're even going to surgery, need to inject a blue dye,
you can do that
with ultrasound guidance using the needle.

Risk of Malignancy in Intraductal Papillary Lesions

Now intraductal papillary lesions the risk
of malignancy or atypia.
So basically if there's a greater than 2% risk.
So anything that we consider to be
considered more like a BI-RADS 4A is anytime you have the
presence of any hard findings.
In other words, anything suspicious for malignancy such
as angular margins.
Anytime you have the soft findings such as calcifications,
if the intraductal papillary lesion expands the duct more
than the amount of fluid does,
anytime the intraductal papillary lesion is longer than two
centimeters, if it involves any type of branching
or any time it involves the terminal ductal lobular unit,
all of these are at greater risk
and definitely should be biopsied.
So this is showing you an intraductal papillary lesion.
You can see the normal duct and the fluid.
It is larger than the size of the duct.
It also has angular margins extending throughout it.
This is just showing you here's the normal duct
with a ductal ectasia
and you can see these angular margins coming off of it
and the papillary lesion is larger than the size
of the amount of fluid inside of that duct.
So these are definitely hard findings.
The angular margins larger than the size of the duct.
This is sort of looking at the rolled nipple technique.
You can see the duct right into the nipple
and these hard findings within this papillary lesion.
Here's another one, looking at soft
findings that are suspicious.
So the presence of microcalcifications
here you can see the duct.
The lesion also extends greater than the amount of fluid
inside that duct and microcalcifications within that.
Once again because of the high water content within these
lesions, a lot of times you're going to see the enhanced
through transmission posterior
to these intraductal papillary lesions.
On color doppler, you can see there's quite a bit
of blood flow also present in that,
not just the single vessel feeding it,
but there's multiple branches that we can see feeding that.
So not just the single vessel that we typically see
with benign intraductal papillomas or papillary lesions.
And this is looking at the ductogram of this patient.
You can see how it extends beyond
and actually fills that area through there.
Intraductal papillary lesions that extend
beyond the lumen of the duct we've talked about.
So here's just a little bit of fluid in the duct.
This is one that is worrisome
that would definitely be given a BI-RADS 4 category if
it's larger than the amount of fluid inside of the duct.
So this is one suspicious if you see a intraductal papillary
lesion longer than two centimeters in size
or if it branches, these are also worrisome.
So these should definitely be biopsied and looked at.
Here's another one that we can see.
Extensive branch pattern.
This is a hydrid type appearance,
but here's the intraductal papillary lesion.
Branching through multiple different areas of that duct

Peripheral Papillomas

Peripheral papillomas basically or any time you have a papilloma involving the
terminal ductal lobular unit instead of the main duct.
These are definitely at higher risk
and we're gonna talk about those a little bit more.
Peripheral papillomas involving the TDLU far from the nipple.
A lot of people think if it's a peripheral papilloma has
to be ones that are the distance from the nipple,
but that's not the case.
A peripheral papilloma just means
that it is a papilloma involving the TDLU itself.
Notice the amount of flow
that you can see within these peripheral papillomas.
Also more than just the single vessel sort of
that we get feeding into the center of it.
But these are peripheral papillomas
and peripheral papillomas also involving the
TDLU right near the nipple.
You can see it branching in coming up through multiple TDLU in this area through here.
This is looking at another patient with both a peripheral
and a central papilloma.
So here is the main duct with the ductal ectasia.
This is a central papilloma.
We also see that there is a papilloma involving the TDLU
and we turned on color doppler.
Looking at these two lesions, look at the difference in flow
with a central papilloma.
We have the single vessel right in the center of it
with the peripheral papilloma.
Look at how much blood flow is present within those.
So peripheral papillomas definitely are more worrisome than
having one within the central duct itself.
This is also just looking at peripheral papillomas
and once again it refers to the origin within a TDLU,
not the distance from the nipple.
Here we can see the ductal ectasia, we can see a little bit
of the duct coming down.
And these are two papillomas that arose in TDLU.
So these are peripheral papillomas.

Sonography of Implants

Now we've talked enough about ducts.
We're gonna go ahead and move into talking about implants.
A lot of people feel that implants should only be evaluated
with MRI and MRI is the best exam
for evaluating patients with implants.
But ultrasound can actually do a fairly decent job also if
you kind of know exactly what to look for in these patients.

Speed of Sound in Implants

Now if we look at the speed of ultrasound,
basically if we scan through saline, the speed
of ultrasound is approximately 1540 meters per second
in scanning silicone.
The speed of sound through
that is at about 970 meters per second.
So what you're going to notice if a patient does not know if
they have a saline versus a silicone implant,
if you scan the patient in the upper outer quadrant
where you get transducer with half of the implant on it
and half of the pectoralis muscle in a saline implant,
you're gonna see just a normal chest wall come across.
But if you're scanning silicone, what you're gonna see
what looks like sort of a cutoff
and it looks like the muscle drops down
and that's just due to the speed of sound.
So this is scanning a saline implant.
You can see that the chest wall muscle comes straight
across, behind that saline.
The speed of sound is approximately 1540.
Whereas when we're scanning a patient with silicone implants
and we have the chest wall coming along, soon
as we hit the silicone, it cuts it or slows at speed down.
So it makes it look like there's a cutoff in the
muscle right at that point.
So that's one way that you can tell a difference if you're
dealing with silicone versus saline implants.
If the patient doesn't know exactly which ones they have.

Types and Appearances of Implants

Now in looking at implants, you can have nontextured,
single lumen, silicone gel or saline implants.
What we're going to see on ultrasound is you're going
to see the outer surface of the implant
and the inner surface of the shell or the implant.
And then the body's reaction to that is a fibrous capsule
that we're going to see.
So what we sort of call this appearance
is the reverse Oreo cookie appearance.
And so this is what we're gonna be looking
for an ultrasound if we're looking for the presence
of an intracapsular rupture or disruption of the shell.
So sort of if we take an Oreo cookie
and invert it, it sort of is looking at what the shell is.
This is the outer surface of the shell.
This would be the inner surface of the shell
and this is what we're going to be looking for.
Sonographically is sort of this trilaminar
of appearance on ultrasound.
Now in looking at these textured single lumen silicone
implants, once again we have the fibrous capsule.
You can have the textured and then the implant wall
or the shell that we'll see on sonography.
You may have a fairly large textured single lumen implant
and there may be even thinner ones.
So this is more of a classical type of appearance
that we will see of the nontextured versus textured
single lumen implants.
So here's sort of scanning a patient.
We can see this is the outer wall of the shell.
This is the inner wall of the shell,
which looks like the reversed Oreo cookie.
And then the body's reaction to that implant,
it builds up this fibrous barrier between that.
So this is the trilaminar
or the three echogenic lines that we're looking for
to see if there is an intact implant.
Here's another example you can see on this
textured single lumen.
This is the outer layer, the inner layer
and then the body's reaction to that
that we can see right along here.
Also, you may have more of a textured implant.
It's very common for us
to see fusions along the edge of the implant.
So we really don't get worried of that.
But this is a textured implant.
You can just sort of see that appearance of the shell
and a little bit of a fusion
that we can pick up right through that area.

Implant Position

Now implants can either be subglandular
or behind the pectoralis muscle retropectoral.
And in evaluating those, the pectoralis muscle
actually gets fairly thin when we take a look at that.
But if you scan the pectoralis, you can see separation sort
of the pectoralis major and minor
and looking to see if it is subglandular or retropectoral.
Much easier to tell this on the mammogram.
Here's one that we can see is subglandular
and here's one that we can see is retropectoral.
'cause you can actually see the pectoralis muscle sort
of splayed over the implant itself.
Mammography is very helpful in evaluating patients
to tell if it is subglandular or retropectoral.
So here's looking at a saline implant.
This is the pectoralis muscle.
We can see this as subglandular.
And here's just a silicone implant where we get that cutoff
of the pectoralis muscle.
But once again, this is also a subglandular silicone
and a subglandular saline implant.

Capsular Contracture

Looking at these on ultrasound now the diagnosis
of capsular contracture is pretty much a clinical diagnosis.
Once the patient lies down on their back,
if the implant looks like they have a couple
of baseball sitting there, you know
that they most likely are gonna have capsular contracture.
One thing that you'll note is
with capsular contracture you'll see bowing
of the posterior wall
of the implant versus a normal implant.
You're gonna sort of have this convexity to it.
Now if you also notice anytime I'm trying
to look at the complete posterior wall of the implant,
you are going to need a lower frequency curved
array transducer.
If you're using your typical breast imaging transducer,
high frequency linear array, a lot
of times you cannot really see this.
But once again, this is pretty much a clinical diagnosis
whether the patient has capsular contracture or not.
Now with capsular contracture you are going
to see a much thicker capsule on the patient.
So here is the shell of the implant, this is the capsule
and just look at how thick that is instead of
that thin echogenic line that we typically see.
You will see a very thick capsule on patients
with capsular contracture.
You may also see calcifications.
Here we can see the normal appearance of the implant,
just a normal little calcification,
a couple of calcifications.
Now if it becomes heavily calcified,
you really can't evaluate the implant sonographically.
As we all know, we're unable to visualize
or see through the calcifications.
So little calcifications like this
really don't cause a problem.
But if the entire implant has heavy calcifications,
we just really cannot evaluate the shell
of the implant at that.

Implant Ruptures and Complications

Now other things that we can see,
you may have partial collapse of the implant.
We may see complete absence of the shell.
You may see radial folds coming in within it.
So we'll look at each of these sonographically.
This is a patient where the shell is absent.
So all we get is a single echogenic line.
This is the capsule itself, but we don't see the shell.
So this is an intracapsular rupture
and most likely the shell is down inside this part of it.
But a lot of these patients, the silicone will stay sort
of in that area or you may have some extravasation.
But this patient definitely has an intracapsular rupture.
The only thing present is the very thin echogenic
shell that we can see there.
You may have partial collapse
or separation of the shell from the capsule.
So we notice in this area here
we have got the echogenic line of the capsule.
Here is the shell,
but yet we can also see a little bit
of separation coming right through this area here.
So in looking at these on ultrasound,
you can pick up partial separation
of the shell from the capsule.
Now beware that you can have reverberations in these
and you wanna make sure you can see we've got the shell here
and this is the echogenic capsule on top of it here
where we can see just a single line
of the echogenic capsule.
This is a true intracapsular rupture or separation of it.
This is a reverberation here we still have our
three echogenic lines.
This is only a single one.
So this is showing you the difference
between the true intracapsular rupture versus
reverberation that we will get with ultrasound.
Just one of our artifacts that we have to deal with.
This is another patient looking at intracapsular
rupture of the left breast.
Here we can see the thin echogenic line of the capsule
in a radial and antiradial scan plane.
And then you get sort
of this stepladder sign is the ultrasound term
for intracapsular rupture.
The linguini sign is what is used for MRI.
I kind of like the word linguini sign better
'cause it's kind of a food.
I mean I don't know why ultrasound has
to call it a stepladder.
I think it it's better if we just call it sort of linguini
but sonographically we do call it the stepladder sign when we
see the intracapsular rupture.
Now very important, once you've seen a patient
that has intracapsular rupture, you're evaluating these,
these are just sort of silicone granulomas
that we can see within this patient
that has this intracapsular rupture.
So different appearances that we can see in evaluating that.
Once we see that you kind of wanna scan
around the periphery when we can tell
that a patient has intracapsular rupture, then the key to
what we're looking for is, is there any extravasation?
But this is evaluating a patient
with bilateral intracapsular rupture.
You can see there's just the single thin echogenic line.
We can actually see the shell partway
through the breast in there and then we're gonna be looking
for extravasation.

Saline Implant Rupture

Now what does it look like if a patient ruptures
a saline implant?
You really don't need ultrasound to make that diagnosis.
It is a clinical diagnosis,
but this was a grandmother
who had their grandchild sitting on their lap
and all of a sudden a little 2-year-old rammed his head back
and actually fractured her implant that you can see here.
And this is what it looks like on ultrasound.
This is what the normal side looks like on the left.
But once again, that's pretty much a clinical diagnosis.
You don't need ultrasound to tell you if there is rupture
of a saline implant.

Radial Folds

Now in looking at implants, we can have radial folds
that we may see within this sort of a smooth shell.
You can also get these little keyhole radial folds
and we still are gonna see
that echogenic fibrous capsule in looking at these patients.
So this is seeing a radial fold.
This is why it's very important when you see these
to scan perpendicular to the fold and parallel to it.
But this is just a radial fold
that we're getting within the implant.
So different things that we can see in ultrasound.
These areas can be more prone to intracapsular rupture just
because of sort of the bending
of the implant through that area.
Now looking at radial fold versus sort
of a normal wave appearance, this is a patient
with a saline implant.
They tend to be fairly easy to actually move these with the transducer
and get this wave type
of appearance versus a normal radial fold
that we can see on these.
So this is sort of coursing in right through this area here.
So just the difference between a radial fold versus the
normal wave appearance that we'll see.
Now if the patient comes in
because they have a palpable lump, you know
that they have implants, we go ahead
and always scan them in the supine position.
A lot of times what they feel
or is palpable may only be present in the upright position.
So this is a patient we did the ultrasound on.
We can kind of see just this little area here
but really not palpate anything.
Once we set the patient up, you can see
that there's definitely this radial fold that appears.
So it's very important to ask the patient if they come in
with something palpable or if
they think they feel something.
Is it when they're sitting upright?
Is it, can they also feel it when they're lying down?
But sometimes you do need to put them in different positions
for evaluating patients with implants.
Now looking at these radial folds,
the fluid can be completely anechoic within it you may have
echogenicity or echogenic fluid within it.
And then at times may we actually get the snowstorm
or the silicone granuloma appearance within this.
So this is a radial fold scanning perpendicular
and parallel to the fold.
We can see that there is completely anechoic fluid
within that area.
This is one that we can see the echogenic fluid within it.
And this is scanning another radial fold
that we can actually see the silicone granuloma that we get
that polar bear
and a snowstorm type of appearance in this patient
with a radial fold.

Herniation

Patients can actually herniate through the capsule.
Once again, this is a patient that presented
with a palpable abnormality.
They had a intracapsular rupture.
This is the actual capsule coming across
and you can see this herniation
of the implant sort of through that.
So you may actually have herniation right
through the capsule and not only through the shell.
This is a patient also that had a palpable abnormality
that was herniation of the implant and scanning this.
At first somebody thought
that there was a cyst in this area,
but when you actually elongate this out,
this is the implant.
Normally it should stop right at this area here,
but this is just disruption of that capsule
and you can see herniation
of the implant through the capsule.
So make sure that you scan it in two different planes.
Looking at it, this was an antiradial,
this was a radial scan just showing you that herniation
of the capsule through the shell.
This is another patient
that we can see a very large herniation of.
This was intracapsular rupture.
You can see that there is some silicone granulomas.
The normal implant should come
and end right along this area here,
but you can see that there was disruption of the capsule
and herniation of the implant.
So when you would cosmetically look at the patient,
you could definitely see that there was difference on the
right breast compared to the left.
Here's another patient that we can see sort of
that echogenic fluid within it.
The implant should come right along this area here, here
and you can see that there is herniation once again
of the implant
through the shell there or through the capsule.

Fill Ports

Now very common for patients with saline implants to present
with a palpable lump.
When they put these implants in, they try
and put the fill port behind the nipple.
Sometimes these may rotate a little bit
and it is a very common cause for patients coming in
with a palpable lump.
What you're going to see is the actual fill port
and the keys are the little stays that they sort
of hold the implant in place.
But if it's not behind the nipple, this is very common
to have a palpable lump.
In these patients that have fairly small breasts.
So you can see that there's very thin tissue.
So you can see how it's very easy for them to present
with a palpable abnormality that is just the valve
of a saline implant.

Extravasation

So once we've evaluated someone
to see if there's any disruption of the shell,
we wanna make sure and see if there's any extravasation
of the silicone once we've evaluated them.
So once we see intracapsular rupture,
is there any silicone in the fluid
or in the space adjacent to that implant?
Now if you scan directly over the center of implant,
everything will look pretty good.
This is a tissue anterior to it.
We can even see deep to that.
But really what you wanna be able
to do is scan all the way around the periphery.
I think the most common location
that we find extravasation is in the upper outer quadrants.
So if I think I see echogenic fluid
or the snowstorm appearance on a patient, I always like
to do split screen comparison.
So this is a patient that has intracapsular rupture
that we can see on this right side.
This is extravasation of the silicone into the soft tissue.
When we do a mirror image,
looking at the upper outer quadrant of the left,
you can just see that there's normal soft tissue in this
area and no extravasation of silicone on that left side.
So kind of how I want to image
that is put the transducer halfway on the implant,
halfway on the soft tissue
and then just sort of scan all the way
around the periphery looking
for any extravasation of the silicone.
And as I mentioned earlier, most often it's going
to be in this upper outer quadrant.
You still definitely wanna check all the way
around the breast tissue also,
but I think the most common location is going
to be the upper outer quadrant.
So here's a patient looking at the right
side versus the left.
You can see that there is extravasation of the silicone.
This is not the upper outer quadrant.
This is directly over a portion of the breast on
that left that we can see the normal soft tissue.
So this is what extravasation of silicone will appear.
The extravasation of silicone in lymph nodes can also be
present that we'll see it.
And once again, it sort of just has
that dirty snowstorm appearance is what extravasation
of silicone will look like.
Now this is a patient that came in,
she had recently had implants put in.
You can see this is actually her capsule through here.
So this is the body's reaction to the implant.
This is the shell.
And then we saw this sort
of echogenic area separating the capsule from the shell.
We weren't sure exactly what we were dealing with.
Was this a true lesion or what's going on?
We asked her to come back three months later for a checkup.
She did not come back for a three month follow up.
She came back a year later for her annual mammogram.
And you can see this exact same area now in within a year
has gone to the classic snowstorm appearance
that you will see with extravasation.
So somehow when they put the implant in,
they must have had a very small leak within it
and a little bit of that silicone
bled out into the tissue separating the
capsule from the shell.
And you can see a year later
how it's turned into this classic snowstorm appearance.
Sonographic axillary lymph nodes very important to look at.
Anytime we see disruption of the shell from the capsule,
we'll check the axilla.
This is a lymph node with silicone extravasation into it,
looking at it in a short axis and a long axis view.

Summary

So in summary, ultrasound is effective as a first test
for patients with nipple discharge.
Ultrasound of ducts within the nipple
and subareolar areas require special maneuvers such
as the two-handed compression, peripheral compression,
and rolled nipple techniques.
Ultrasound can detect causes
of discharge other than papilloma.
The diagnosis of ductal ectasia requires caution.
Papillary lesions are often associated
with generalized duct ectasia
and sonography can play an important role in the evaluation
of breast implants.
Thank you for your time.