1. Sonography of the Breast
Ultrasound of The Breast Part II
Modules I and II
Introduction
Instrumentation
Holdorf PhD, MPA, RDMS (Ob/Gyn, Ab), RVT, LRT(AS)

2. Module One Introduction
Module Two Instrumentation
Module Three Anatomy and Physiology
Module Four Mammography
Module Five Sonography
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

3. Part II contents-everything from this point forward
Sonographic Terminology
Echogenicity
Transducers
Depth
Output power
Focus
Gray Scale
Artifacts
Doppler
Spatial Compounding
Elastography

4. Anatomic Layers
Standard Anatomic Reference
Embryologic Development
Arterial Supply
Venous Return
Lymphatic system
Nerves
Physiology and Hormonal Influences
Breast Exam Guidelines
Breast Self-Examination
Mammography
Mammographic Views
Mammographic Examination
Benign and Malignant Mammographic Features
Calcifications

5. Sonographic Examination
Breast Sonography
Sonographic Examination
Patient History
Positioning
Transducer Pressure
Scan Planes
Annotation
Stand-off Pad
Normal Sonographic Appearance
Dynamic Examination
Compression
Echo Palpation
Fermitus
3D/4D Breast Sonography
Sonographic Features of Benign Disease
Sonographic Features of Malignant Disease

6. Miscellaneous Benign Disease
Breast Cysts
Simple Cyst
Non-Simple Cysts
Galactocele
Sebaceous Cyst
Fibrocystic Changes
Fibroadenoma
Papilloma
Lipoma
Fibroadenolipoma
Lactating Adenoma
Inflammation
Miscellaneous Benign Disease
Skin thickening
Nipple Discharge
Sclerosing Adenosis
Radial Scar
Mondor’s Disease
Precocious Puberty
Gynecomastia

7. Non-Invasive Breast Cancer
Epidemiology
Risk Factors
Non-Invasive Breast Cancer
Ductal Carcinoma In Situ
Lobular Carcinoma In Situ
Invasive Breast Cancer
Invasive Ductal Carcinoma
Invasive Lobular Carcinoma
Medullary Carcinoma
Colloid Carcinoma
Tubular Carcinoma
Papillary Carcinoma

8. Miscellaneous Cancer Topics
Paget’s Disease
Inflammatory Carcinoma
Multifocal/Multicentric Cancer
Male Breast Cancer
Phyllodes Tumor
Lymphoma
Metastasis
BIRADS categories

9. Digital Mammography
Computer Aided Detection (CAD)
Magnetic Resonance Imaging (MRI)
Nuclear Medicine
PET Scan
Ductography
Ductoscopy
Sentinel Node Procedure
Cytology and Histology

10. Breast Implants Types of Implants Implant Placement Imaging Implants
Complications
Implant Rupture

11. Role of Sonography in Invasive Procedures
Cyst Aspiration
Needle Localization
Fine-Needle Aspiration
Core Biopsy
Vacuum-Assisted Biopsy
Advanced Breast Biopsy Instrument
Surgical Biopsy
Specimen Imaging

12. Breast Cancer Staging
Breast Cancer Treatment
Surgery
Reduction Mammoplasty
TRAM flap
Radiation Therapy
Chemotherapy
Hormone Therapy
Biologic Therapy

13. Module one: Introduction

14. Sonographic Terminology from the AIUM (American Institute of Ultrasound in Medicine)
Acoustic Impedance- The resistance that a material offers to sound wave travel.
Amplitude – The strength or height of a sound wave measured in decibels.
Anechoic- The appearance of having no internal echoes (ech0 free) on a sonographic image. Synonyms: echolucent, sonolucent.
Artifact- an echo feature present or absent in a sonographic image that des not correspond to the presence or absence of a real structure. Common artifacts in breast imaging include enhancement and shadowing.

15. Attenuation- the reduction of intensity (and amplitude) of a sound wave as it travels through a material. Attenuation is due to absorption, reflection, and scattering.
Complex- A structure in the body that contains both solid and cystic components.
Cystic- any fluid-filled structure in the body.
Echogenic- A structure or medium that produces echoes.
Echo Shadowing- decreased echo amplitude distal to the edge of a structure. This artifact results from refraction of the sound beam.
Enhancement – Increased echo amplitude returning from regions lying beyond an object that causes little or no attenuation of the sound beam (Typically a cystic structure). This artifact results in a brighter than normal appearance.

16. Heterogenous – a structure that has an uneven texture (hypoechoic and hyperechoic echoes throughout). May be used to describe a mass or tissue in general. Synonym: non-uniform.
Homogenous – a structure that has a smooth, uniform texture. May be used to describe a mass or tissue in general.
Hyperechoic- A region in a sonographic image where the echoes are brighter than normal or brighter than surrounding structures. Synonyms: echodense, sonodense, sonopaque.
Hypoechoic – a region in a sonographic image where the echoes are not as bright as normal or are less bright than surrounding structures.

17. Ipsilateral – on the same side.
Contralateral – on the opposite side.
Isoechoic – having the same echogenicity as another structure or surrounding tissue.
Noise- spurious echoes throughout the image. May cause echoes to be seen in cystic structures.
Real-time- The scanning and display of sonographic images at a sufficiently rapid rate so that moving structures can be SEEN to move at their natural rate; frame rates of 15 frames per second or greater are considered real-time. Real-time imaging allows the sonographer to perform dynamic techniques while scanning to better interrogate breast structures.

18. Reverberation – a type of artifact causing linear echoes parallel to a strong interface; sound is returned to the transducer than into the tissues repeatedly (bouncing artifact).
Ring Down- a particular type of reverberation artifact in which numerous parallel echoes are seen for a considerable distance.
Sensitivity – the ability to diagnosis disease in a patient when disease is present.
Shadowing- a reduction in echo amplitudes distal to a strongly attenuating or reflecting structure (typically caused by a dense, solid structure). This artifact results in a less bright than normal appearance.

19. Solid- A structure in the body that produces echoes.
Sonodense – the result of an attenuated sound beam traveling through a solid structure. Synonym: Hyperechoic, echodense, or sonopaque.
Sonolucent- the result of an unattenuated sound beam traveling through a fluid-filled structure. Synonym: anechoic, echolucent
Superficial- toward the body surface.
Deep-away from the body surface or internal.
Texture- the pattern of echoes seen from a mass or area of interest in the body.

20. Homework: TAKE HOME TEST
Case presentation: Mammogram and Ultrasound correlation 1. <25 y/o with DCIS 2. <25 y/o with Fibro adenoma 3. Woman with Paget’s Disease 4. Woman with Micro-calcifications 5. Lobular Carcinoma in situ (LCIS) 6. Woman with multicentric cancers 7. Woman with multifocal cancers

21. Breast Cyst - anechoic

22. Complex Cyst

23. Breast cyst – edge shadowing and enhancement

24. Fibroadenoma – homogeneous and isoechoic

25. Cyst aspiration needle with reverberation

26. Calcified breast mass - shadowing

27. Echogenicity
The ultrasound system sends high frequency sound waves into the breast which reflect off tissues and boundaries. This reflection (echo) is represented on the image as a series of black, white, and gray areas based on the reflective nature of the tissue. If the tissue strongly reflects the sound, it will appear white (hyperechoic). If the tissue weakly reflects the sound, it will appear dark (hypoechoic). If the tissue provides no reflection of the sound, it will appear black (anechoic).
This vocabulary is specific to Sonography and is described as the echogenicity of a structure/tissue.

28. Echogenicites 1. Mid level gray fat
2. Hyperechoic Fibroglandular tissue
3. Hypoechoic Complicated cyst
4. Hypoechoic/Anechoic Rib Shadow
5. Hyperechoic Cooper’s Ligament
6. Hyperechoic Skin
Hypoechoic relative to ligaments

30. Module Two: Instrumentation

31. Instrumentation
Breast Sonography is extremely operator-dependent. Therefore, it is essential to use appropriate equipment and be properly schooled in breast Sonography in order to achieve diagnostic accuracy.
Sonographic images are created using the B-Mode (brightness) principle. This offers a gray scale image of the breast.
The set-up of the ultrasound system (machine) should include selecting the most appropriate transducer and optimizing the depth, overall gain, TGC, output power, focus, and gray scale. Color and power Doppler techniques continue to play a useful role in breast imaging and also require fine adjustment.

32. Transducers Transducer selection is critical in breast imaging.
Frequency
A 10.0 – 18.0 MHz frequency is optimal
Need high frequency probe for superior axial and lateral resolution (detail) while maintaining penetration to chest wall.
A broadband transducer (wide frequency range) is optimal.
Trade-off; High frequency probes yield superior image detail while losing penetration ability. Low frequency probes penetrate deeper but lose image detail.

33. Probe Design A linear Array transducer is optimal.
Produces a rectangular image
Allows direct contact scanning perpendicular to the chest wall.
Accurate measurements can be recorded by avoiding beam divergence artifact (this is achieved with a rectangular image vs. a sector image).
Interventional procedures (i.e., cyst aspiration, biopsy, and needle localization, etc.) can be accurately guided with a linear array probe.
A curved Array transducer may be used to supplement the sonographic examination if a mass is too large to fit on a linear image.
Using the lower frequency curved array probe provides a larger field of view at the expense of lost resolution.

35. A 1-D Linear or 1.5 D Matrix Array Transducer may be utilized
Most linear array transducers used in breast Sonography are 1-D arrays
1-D arrays have a single element stretched across the short axis of the probe.
1-D arrays offer a fixed focus in the elevation plane (short axis)
1.5 D matrix array transducers have multiple elements along the short axis of the probe.
1.5 D arrays offer some electronic focusing in the elevation plane.
2-D transducers are not currently available.

37. Depth
Depth should be sufficient to visualize the breast tissue from skin to chest wall. Breast size will vary from one patient to the next. However, an imaging depth between 3 and 6 cm should be adequate.
Imaging of the breast should include
1. skin
2. breast parenchyma
3. pectoral muscle
4. chest wall

39. For Previous Slide 1. Skin 2. Breast Parenchyma 3. Pectoral Muscle
4. Chest Wall

40. Gain
Receiver gain is the amount of amplification applied to a returning echo. An echo’s brightness is controlled by gain. Gain is the most frequently adjusted control. It is optimized for each patient depending on several factors. These factors include breast size, thickness, and tissue density.
There are typically three adjustments for gain on the ultrasound control panel:
1. Overall Gain
2. TGC
3. Auto Gain Optimization
OVERALL GAIN
Controls the level of brightness of all echoes appearing on the image. The Sonographer has the ability to increase or decrease the overall brightness by using this control.

41. TGC (Time Gain Compensation)
Allows for brightness to be controlled at varying depths throughout the image. The top control adjusts brightness in the near field of the image. The bottom controls adjust brightness in the far field.

42. Auto Gain Optimization
Most state-of-the-art ultrasound systems offer an Auto Gain Optimization control. This feature automatically optimizes the overall gain and TGC functions with each imaging area. If the overall affect does not produce an optimized image, the sonographer may still need to make fine adjustments with the overall gain and TGC.

43. Output Power
Output power is the amount of voltage applied to the transducer to create a sound wave. This control determines the patient’s exposure to ultrasound energy. Therefore, the sonogphaer should consider prudent use of output power. All state-of-the-art sonographic systems, however, function at a safe power setting while operating at 100% output power.
Sonographers should remember the ALARA principle:
Output power should be set “As low as reasonably achievable.”

44. What happens when the power is decreased?
So, when should the sonographer decrease the output power? And, what happens to the image?
What happens when the power is decreased?
Answer: The image gets darker
Can the brightness be increased without increasing the power gain?
Answer: Yes, by increasing the gain.
Does increasing the gain have any effect on patient exposure to ultrasound energy?
Answer: No
So, in THEORY
If your image is too bright, decrease the output power.
If your image is too dark, increase the receiver gain.
In day-to-day practice, however, the output power is usually at 100%. The gain is most frequently used to adjust the image brightness.

45. Focus
Multi-focus or variable (Adjustable) electronic focusing will achieve optimal breast detail.
The use of multiple focal zones will provide excellent resolution of full depth of the image. This may significantly reduce the frame rate. Multiple focal zones, however, are still recommended.
Trade-off: Multiple focal zones will yield the best resolution throughout the entire image at the expense of a slow frame rate.
Increased focal zones = decreased frame rate.

46. Multiple focal zones

47. Single focal zone (single focus)

48. Elevation Plane focus
Elevation plane focus is defined as the focus in the short axis or elevation plane (short side) of an electronic transducer.
1-D array transducers have a fixed (manufacturer set) elevation plane focus. 1.5 D array transducers have some electronic focusing in the elevation lane.
Most probes used in breast imaging are conventional 1-D linear array transducers. Therefore, manufacturers create high frequency transducers with a shallow focus in the elevation plane and low frequency transducers with a deeper focus. A 10.0 to 18.0 MHz probe must be utilized for breast Sonography in order to obtain elevation plane focus at 1.0 to 2.0 cm depth.
10MHz =1.5 cm Elevation Plane Focus

49. Elevation Plane Focus

50. Gray Scale
Echoes returning from breast tissue are assigned to a specific shade of gray based on their echo strength. This function of the ultrasound system is known as Gray Scale Mapping or Dynamic Range. The sonographer controls the selection of the gray scale map or dynamic range by using the breast or small part examination preset or protocol control. Fine adjustments to the dynamic range may also be made during scanning.
Generally for Breast imaging, a broad gray scale map or dynamic range is used. This provides a wide range of gray shades to be displayed while demonstrating subtle tissue differences. A map with too few gray shades may not accurately demonstrate low-level echoes within a cyst or solid lesion.

51. Artifacts
Artifacts exist in breast sonography as they do imaging any other organ structure. Some artifacts have proven helpful and may aid in determining certain characteristics about tissue. Artifacts also hinder imaging capabilities.
Helpful artifacts
Acoustic enhancement – Generally associated with a cystic/benign lesion.
Shadowing – generally associated with a solid/malignant lesion.

52. Shadowing artifact with breast cancer

53. Unwanted artifacts
Reverberation – artifactual linear echoes parallel to a strong interface. Has a distinct “stepladder” or “venetian blind” appearance.
Side or Grating lobe – Secondary sound sources off the main sound beam that place artifactual echoes within a cyst.
Slice (section) Thickness – Unwanted echoes from the thickness of the sound beam in the elevation plane that place artifacts within a cyst.
Nipple Shadowing – shadowing in the subareolar region may be eliminated by angling the transducer posterior to the nipple or by using the “rolled nipple” technique.
Volume Averaging – decreases contrast resolution and spatial resolution (both axial and lateral). Places unwanted echoes in cysts.

54. Doppler
Conventional Color Doppler and Power Doppler can be useful in evaluating breast tissues. Power Doppler is typically more sensitive to low velocity flow and offers no angle dependence. Neither is reliable, however, in distinguishing benign from malignant lesions. Both benign and malignant masses may demonstrate internal flow characteristics. Both may also demonstrate a normal low velocity flow state (in comparison to surrounding tissues). Why use Doppler with breast imaging?

55. Doppler is helpful in distinguishing:
Solid vs. Cystic – Positive flow within a lesion confirms a solid nature.
Inflamed vs. non-inflamed tissue- Doppler signal will increase due to increased flow to an inflammation.
Complicated Cyst vs. complex cyst – vs. intraductal papilloma – Doppler signal will be absent in the debris of a complicated cyst but may be evident within the solid component of a complex cyst or intraductal papilloma.
PRESSURE: Minimal transducer pressure should be used with Doppler scanning techniques of the breast. The small vessels within the breast tissue are easily compressed.

56. Doppler technique: In order to optimize Doppler imaging, the sonographer should establish a technique for low velocity flow states:
This includes
1. Low velocity Scale
2. Low filter setting
3. Optimal Doppler Gain Setting
4. Increased PRF for high flow velocities.

57. Solid or Cystic? Conventional color Doppler reveals solid mass

58. Spatial compounding
Uses compounding technique to combine ultrasound lines acquired from different scanning directions (angles). Improves tissue differentiation, margin visualization, and internal architecture creating a “smoother” more realistic image.
Advantages
Clears cysts
Reduces Speckle and other noise artifacts (clutter)
Disadvantages
Reduces acoustic enhancement and shadowing artifact
Subject to blurring

59. Elastography
Elastography is a diagnostic method that evaluates the elastic properties of tissue. Breast tissues and masses vibrate or compress differently based on their firmness.
It is well known that breast fat is highly elastic and compresses significantly. It is also known that benign lesions tend to be soft (compressible) and malignant lesions tend to be hard (very firm and non-compressible.
Therefore, elastography may have the potential to differentiate benign from malignant breast tumors (distinguish BIRADS 3 form BIRADS 4 lesions) and potentially reduce the number of biopsies.

61. FIN