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Breastsonography
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High frequency transducers (min 7MHz) tominimize volume averaging
The depth of focal zone must be adjusted tothe depth of any lesion to minimize volumeaveraging and mischaracterization of thelesion
!olume averaging can alter the chogenicityso much that cystic lesions falsely appearsolid and hypoechoic solid lesions becomeisoechoic and inconspicuous
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in very super"cially located lesion#stando$ of gel is used to minimize
volume averagingMisposition focal zines can lead to
severe volume averaging andmischaracterization of even midsized
lesions# particularly if the focal zonesare positioned much too deeply
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Breast composed of %
&'* lobes % +obar duct
,maller branch duct
+obules
,upporting stromal tissues %
-ompact interlobular stromal "brous tissue +oose periductal stromal "brous tissue
.ntralobular stromal "brous tissue
/at
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/unctional unit of the breast is Terminal0uctolobular 1nit (T0+1) consists of %
+obule# consists of % .ntralobular segment of the terminal duct
.ntralobular segment of the ductules
+oose intralobular stromal "brous tissue
23tralobular terminal duct
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Breast divided into 4 zones % 5remammary zone 6 subcutaneous zone % lies
beteen the s8in and the anterior mammary fascia Mammaryzone % lies beteen anterior mammary
fascia and the posterior mammary fascia# contains %lobar ducts# their branches# most of the T0+1s andthe most of the "brous stromal elements of breast
9etromammary zones % fat# blood vessels#
lymphatics less apparent on sonogram becausesonographic compression :attens theretromammary zones against the chest all
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;ormal anatomic structures of thebreast %
Hyperechoic % compact interlobularstromal "brous tissue# anterior andposterior mammary fasciae# cooper
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;ormal mammary ducts that are not ectaticcan appear %
5urely isoechoic# hen the centrallylocated hyperechoic duct all cannot bevisualizzed because a poor angle ofincidence or suboptimal transducer
=r as a central# bright echo surrounded byisoechoic loose tissue hen the apposedalls of the central duct can be optimallydemonstrated
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These are maneuvers to visualize theducts ithin the nipple% 5eripheral compression techniqueTo handed compression technique
9olled nipple technique
1seful for evaluating patient ith nipple
discharge
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;ormal T+01s are about mm indiameter# but may be as large as ' mm
in patients ith "brocystic change#adenosis
.n patients ho are pregnant orlactating and adenosis# T0+1s enlarged
and increased in number
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=ne of the most valuable features ofhigh frequency coded harmonic imaging
is that it tends to ma8e pathologic solidnodules appear relatively morehypoechoic and conspicuous in abac8ground of isoechoic tissues
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+ymphatic drainage % deep super"cialsubdermal lymphatic netor8
periareolar ple3us (,appey
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4 level of a3illary lymph node % +evel &% lie peripheral to the inferolateral edge of the
pectoralis minor
+evel % lie posterior to the pectoralis minor
+evel 4 % lie pro3imal to the superomedial border ofthe pectoralis minor (infraclavicular nodes)
/rom level 4 nodes metastases may progress tointernal jugular or supraclavicular lymph nodes
9otter nodes % lie beteen the pectoralis majorand minor a frequent source of chest allrecurrences
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Metastase can involve thesupraclavicular lymph node# but
metastases must involve levels and4 a3illary lymph nodes or internalmammary and internal jugular lymphnodes "rst
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B.9>0, Birads & % sonographically normal
tissues that cause mammographic or
clinical abnormalities Birads % benign entities and include
intramammary lymph nodes# ectaticducts# all simple and many complicated
cysts# and de"nitively benign solidnodules# such as lipoma and hamartoma
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Birads 4 % ?probably benign@ lesions# andincludes some complicated and comple3
cysts# small intraductal papillomas and asubset of "broadenomas
Birads A % ?suspicious% Aa % ?mildly suspicious@
Ab % ?moderately suspicious@
Ac % ris8 of malignancy is greater than '* toless than C'
Birads ' % ?malignant@
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Birads & and routine screeningfollo up
Birads 4 surgical biopsy# imageguided needle biopsy# or short intervalsonographic follo up
Birads A biopsy
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,pecial Breast Technique +esion that are more than 4* compressible
are fatty ith a high degree of certainty D
either a normal fat lobule or a benign lipomaHeeling and toeing of the transducer
minimizing critical angle shadoing arisingfrom -ooper
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0oppler ultrasound assessment dependsin compression pressure blood :o
can easily be decreased if compressionis too vigorous
5ositional changes are important inassessment of comple3 cyst# :uiddebris
levels# mil8 of calcium# fat:uid levels
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Main indication 5alpable lump /or tiny and super"cial lesion just under
the s8in 0ense tissue in the area of the palpable
lump
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-riteria to evaluate ,ize correlation Measurement a lesion (hich has a ater
density in mammography) should bemade outside to outside to include thecapsule that surrounds the cyst and solidnodule# because the capsule is aterdensity and ill be included in the
measurement of the lesion onmammogram
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,hape -orrelation Must consider phenomena %
5artial compressibility 9otary forces
5artially compressible lesions that appearspherical on mammography are oval shapedon sonography
Ehen the lesion is spherical in mammographyand incompressible# the shape ill bespherical in sonography
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Mammographic and sonographiccompression apply di$erent rotatory
forces on lesions that are not sphericalMammographic compression pulls lesions
aay from the chest all# and tends torotate the lesion so that its long a3is liesperpendicular to the chest all
,onographic compression
push lesioncloser to the chest all and tends to rotatethe lesion
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+ocation or 5osition -orrelation Mammographic compression pulls a lesion
aay from the chest all ,onographic compression pushes the
lesion closer to the chest all
The lesion ill loo8 deeper in sonography
than in mamography
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,urrounding tissue density correlation 23% a lesion that protrudes into the
subcutaneous fatfrom the mammaryzone# should lie at the junction of thesubcutaneous fat and mammary zonealso on the sonogram
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,onographic /inding ;ormal tissue and variations .ncluding % duct ectasia# "brocystic change#
benign proliferative disorders
can causemammographic and sonographic abnormalities>;0.s (>berrations of normaldevelopmentand involution)
>;0.s can also presents as cysts and solidnodule in sonography false positive result atbiopsy
>;0.s can be characterized as B.9>0, #4# or A
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,imple cyst 0e"nitively benign
.f strict criteria for a simple cyst are met#the lesion is B.9>0,
-omplicated and comple3 cyst can becharacterized as B.9>0, #4# and A
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,olid ;odules >utomatically indication for biopsy
.f it B.9>0, 4 must have a or loerris8 of being malignant
,piculated and circumscribed cancersdi$er greatly