1. Eastern Florida State College SON 2147
Sonography of The Breast
Holdorf PhD, MPA, RDMS (Ob/Gyn, Ab, BR), RVT, LRT(AS), CCP

2. Sonography of the Breast
Part one: Introduction/Overview
Anatomy and Physiology
Breast Development
Breast Screening
Sonographic Evaluation
Benign Conditions
Malignant Conditions
Interventional Breast Procedures

3. Part Two Part Three Module One Introduction Module Two Instrumentation
Module Three Anatomy and Physiology
Module Four Mammography
Module Five Sonography
Part Three
Module Six Benign Disease
Module Seven Malignant Disease
Module Eight Other Breast Imaging and Testing
Module Nine Breast Augmentation
Module Ten Invasive Procedures
Module Eleven Staging and Treatment

4. Practice Mock Final Exam
Homework Assignments due every week as assigned which includes various SDMS Breast Webinars.

5. Table of contents for In-Dept Introduction
Anatomy and Physiology of the Breast
Breast Development
Breast Screening
Sonographic Evaluation
Benign Conditions
Malignant Conditions
Interventional Breast Procedures

6. BI-RADS Breast Imaging-Reporting and Data System (ACR)
Assessment Codes:
0 Incomplete
1 Negative
2 Benign findings (100%) CYST
3 Probably benign (< 2% chances of cancer)
4 Suspicious (3-94% chance of cancer) Sub cats
5 Highly suggestive of malignancy (> 95%)
6 Known biopsy proven cancer

7. Mammography Reports BI-RADS Recommendations
0 Needs additional imaging evaluation (incomplete study)
Annual screening (> 40 yearly)
Annual screening
Short-term follow-up (usually 6 months)
Tissue sampling is required
Definitive treatment required (biopsy or surgery)
Definitive treatment required

8. Sub cats for BI-RAD 4 4A: low suspicion for malignancy
4B: intermediate suspicion of malignancy
4C: moderate concern, but not classic for malignancy

9. Breast Composition Categories
1: Almost entirely fatty
2: Scattered fibro-glandular densities
3: Heterogeneously dense
4: Extremely dense

10. The Breast is a modified sweat gland located in the superficial fascia of the anterior chest wall.

11. The major portion of the breast tissue is situated between the second or third rib superiorly… the sixth or seventh costal cartilage inferiorly… the anterior axillary line laterally… and the sternal border medially.

13. In many women, the breast extends deep toward the lateral upper margin of the chest and into the axilla.
This extension (the axillary tail of the breast) is referred to as the tail of Spence.
Actually, the breast is TEAR SHAPED.

14. The tail of Spence

15. The surface of the breast is dominated by the nipple and the surrounding areola.

16. A few women may have ectopic breast tissue or accessory (supernumerary) nipples.

17. Ectopic breast tissue and accessory nipples are usually located along the mammary milk line, which extends superiorly from the axilla downward and medially in the oblique line to the symphysis pubis of the pelvis.

18. Sonographically, the breast is divided into three layers:
Sonographically, the breast is divided into three layers: The subcutaneous layer-8 The mammary (glandular) layer-9 the retro-mammary layer-10

19. The subcutaneous and retromammary layers are usually quite thin and consists of fat surrounded by connective tissue speta.

20. The fatty tissue appears hypoechoic while the ducts, glands, and supporting ligaments appear echogenic.

21. The mammary/glandular layer includes the functional portion of the breast and the surrounding supportive (stromal) tissue.

22. The functional portion of the breast is made up of 15 to 20 lobes, which contain the milk-producing glands, and the ductal system, which carries the milk to the nipple.

23. The lobes emanate from the nipple in a pattern resembling the spokes of a wheel.

24. The upper-outer quadrant of the breast contains the highest concentration of lobes.

25. This concentration of lobes in the upper-outer quadrant of the breast is the reason a majority of tumors are found there.

26. Each lobule contains acini (milk-producing glands) which are clustered on the terminal ends of the ducts like grapes on a vine.

27. The terminal ends of the duct and the acini form small lobular units referred to as terminal ductal lobular units (TDLU).

28. The space between the lobes is filled with connective and fatty tissue known as stroma.
These stromal elements are located both between and within the lobes and consists of dense connective tissue, loose connective tissue, and fat.

29. Connective tissue septa are collectively called Cooper’s ligaments.

30. Muscles sonographically appear as a hypoechoic interface between the retromammary layer of the breast and the ribs.

31. Subcutaneous fat generally appears hypoechoic, whereas Cooper’s ligaments and other connective tissue appear echogenic and are dispersed in a linear pattern.

32. The mammary/glandular layer lies between the subcutaneous fatty layer anteriorly and the retromammary layer posteriorly.

33. The ribs sonographically appear as hyperechoic rounded structures with dense posterior shadowing.

34. The size and shape of the breast varies remarkably from woman to woman
The size and shape of the breast varies remarkably from woman to woman. The size and shape of the breast varies over time because of the changes that occur during the menstrual cycle, with pregnancy/breast feeding, and during menopause.

36. Breast Pain Cycle

37. Generally, in a young woman, fibrous tissue elements predominate and the resulting appearance on mammography and ultrasound is a dense, echogenic pattern of tissue.

38. In a pregnant or lactating woman, the glandular portions of the breast poliferate remarkably. (non-lactating vs. engorged breast)

39. As a woman ages, the glandular breast tissue undergoes cell death and is remodeled by the infiltration of fatty tissue.

40. The main arterial supply to the breast comes from the internal mammary and the lateral thoracic arteries.

42. Venous drainage is mainly provided by superficial veins that can be seen sonographically just under the skin.

43. Lymphatic drainage from all parts of the breast generally flows to the axillary lymph nodes. Only about 3% of lymph is eliminated by the internal chain, whereas 97% of lymph is removed by the axillary chain.

44. The male breast In males, the nipple and areola remain relatively small

45. The male breast normally retains some ductal elements beneath the nipple, but does not develop the milk-producing lobular and acinar tissue.

46. Male breast hypertrophy is called benign Gynecomastia.

47. Although breast cancer is uncommon in males, it does occur
Although breast cancer is uncommon in males, it does occur. Approximately 1300 new cases are diagnosed each year within the United States.

48. Physiology of the Breast
The primary function of the breast is to transport fluid.
The breast includes the fat, ligaments, glandular tissue, and ductal system that work together to provide a fluid transport, and only one entity in this group produces milk.

49. The ductal system is critical in the transport of fluids within the breast and it is also a source for ductal pathologic conditions.
Ducts consist of epithellum cells, which line the interior of the ducts, and a myoepithelium set of cells, which controls the contractibility of the ducts.
Milk is produced within the acini and is carried to the nipple by the ducts.

50. Hormones
The female breast is affected by hormonal levels during each menstrual cycle and is further affected by both pregnancy and lactation.

51. Breast development begins before menarche and continues until the female is approximately 16 years old.

52. During this time, the ductal system proliferates under the influence of estrogen.
During pregnancy, acinar development is accelerated to enable milk production by estrogen, progesterone, and prolactine.
Prolactine is a hormone produced by the pituitary gland, which stimulates the acini to produce and excrete milk.

53. The physical stimulation of sucking by the baby initiates the release of oxytocin which further incites prolactin secretion, stimulating additional milk production. (Oxytocin delivers milk)