Breast Sonography general goal. Optimizing Breast Sonography. BUS indications -- all. Breast Sonography specific goals.

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1 Optimizing general goal Cindy Rapp BS, RDMS, FAIUM, FSDMS University of Colorado Hospital Denver, Colorado to make a more specific diagnosis than can be made with clinical and mammographic findings alone specific goals prevent unnecessary biopsies prevent F/U mammograms guide interventional procedures improve clinical and mammographic interpretive skills find malignancies missed by clinical and/or mammographic exams fu 7% mamm 32% BUS indications -- all pn 5% se 2% nt 2% ma-pa 6% palp 46% palp ma-pa mamm fu pn se nt Proper Equipment Equipment Requires a near-field high resolution probe Spatial resolution axial resolution lateral resolution Contrast Resolution

2 Equipment Lateral resolution minimize volume averaging Two planes long axis short axis or elevation plane elevation plane E L E V A T I O N P L A N E L O N G A X I S Equipment lateral resolution SKIN Elevation Plane Focus ELEVATION PLANE FOCUS 10 MHz 5 MHz FL 1.5 CM SU B Q FA T FL 3.5 CM Elevation Plane Focus 1.5 CM 3 CM MAMMARY ZONE RETROM A M M A RY PECTORALIS LUNG SKIN Elevation Plane Focus 1.5 CM Patient Positioning right breast Patient Positioning and Annotation LPO Supine LLD

3 hand behind head thins breast and improves angles Annotation RT 12 2? AX SA ANTERIOR VIEW Annotation RT 12 2C Annotation RT 12 2C AX A B C A B C SA LATERAL VIEW LATERAL VIEW ANTERIOR VIEW Annotation RT 12 2C LT 1:30 3B Scan Planes Radial Anti-Radial LT 12:00 12:00 AX AX A A B C SA SA C B A B B C A AR RAD LATERAL VIEW 6:00 ANTERIOR VIEW 6:00 LATERAL VIEW C

4 Scan Planes Radial Anti-Radial normal anatomy SKIN SUBQ FAT COOPERS LIGAMENTS PRE-MAMMARY FASCIA MAMMARY ZONE RETROMAMMARY FASCIA RETROMAMMARY ZONE PECTORALIS Normal Anatomy apparent duct duct plus isoechoic loose periductal stromal fibroelastic tissue duct ectasia virtual variant of normal Normal variations and age changes

5 Normal variations and age changes Normal variations and age changes Normal variations and age changes Normal variations and age changes Normal variations and age changes Mammographic Sonographic Correlation

6 There is one difference between breast sonography and mammography algorithms mammography obtaining good images easy interpretation of images difficult - operator dependence - sonography obtaining good images difficult interpretation of images easy mammographic-sonographic correlation -- scan planes -- transverse plane during ultrasound accurately reproduces transverse plane on CC mammograms mammographic-sonographic correlation -- scan planes -- oblique planes during ultrasound less predictably reproduce oblique planes on MLO mammograms US-mammographic correlation -- location lateral lesions appear to be located more superiorly than they really are on MLO mammograms... and... the farther peripherally they lie, the higher they project on MLO view US-mammographic correlation -- location How I remember this! Medial lesions appear to be located more inferiorly than they really are on MLO mammograms... and... the farther peripherally they lie, the lower they project on MLO view

7 Mammographic Densities: fat calcium water Mammographic Densities Water density: cyst fibrous tissue glandular tissue solid nodule muscle / skin Mammographic-Sonographic Correlation Fatty Tissue Mammographic-Sonographic Correlation Glandular Tissue RCC LCC RCC LCC Mammographic-Sonographic Correlation Fibrous Tissue Mammographic Sonographic Correlation size shape location surrounding tissue density RCC LCC

8 Mammographic - Sonographic Correlation Mammographic - Sonographic Correlation Size Must take into account all that is water density Size Always include the capsule Mammographic - Sonographic Correlation Size - water density = fibrous pseudomass Mammographic - Sonographic Correlation Shape 90 rotation difference Mammographic - Sonographic Correlation Shape 90 rotation difference Mammographic - Sonographic Correlation Shape & Location Mamms compression pulls long axis perpendicular to chest wall U/S compression pushes long axis parallel to chest wall

9 Mammographic-Sonographic Correlation location -- always closer to chest wall on US Mammographic-Sonographic Correlation shape and surrounding tissue BIRADS - 4 BIRADS - 2 Mammographic-Sonographic Correlation if you can t find it it s solid!! -- look for capsule System Optimization Always Set Fat Medium Gray

10 Fat set as Black Fat set as GRAY High-Grade Invasive Ductal Carcinoma DIAGNOSTIC BREAST ULTRASOUND PALPABLE ABNORMALITY Specific goal #1 Can prevent biopsy by showing: Palpable Nodules Conservative Aggressive Simple cyst Fibrous pseudomass Complex cyst (most) Fibroadenoma Palpable Lump Palpable Lump when the indication is palpable lump, you must palpate while scanning for larger lesions, roll finger under the probe while scanning Normal Fibro-Glandular Tissue

11 Palpable Lump Simultaneous Palpation and Scanning Fibroadenoma Simple Cyst Tension Cyst Lazy Cyst Standoff Pads Gel standoff Gel Standoff Near-field Volume Averaging Palpable Lump 5 mm deep no stand-off focal zone too deep gel stand-off focal zone correct

12 Split-Screen Imaging For Asymmetric Density Hanging Lake Glenwood Canyon, Colorado Split-Screen Mirror Images Split Screen Mirror Images Split screen with and w/o compression RT LT Split Screens with & w/o compression Compressibility Split-Screen Comparison for compressibility > 30% compressible - fat, lipoma 0-25% compressible - FA 0-15% compressible - CA Lipoma X X + +

13 Fibroadenoma or Fat Lobule? 3 maneuvers to prove fat lobule 1) Compressibility - 30% 2) Rotate 3) Line Split screens with & w/o compression Variable Compression 2D Imaging Fibroadenoma Split screen with and w/o compression for rotation rotation no rotation - FA - CA

14 Compression eradicates artifactual shadowing Compression eradicates artifactual shadowing Cancer next to cyst Artifactual Shadowing Which one is a cancer? Artifactual Shadowing

15 Nipple Straight AP approach Peripheral compression Two-handed compression Rolled nipple technique Once you understand, you ll love it!

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