Breast Sonography. National Certification Exam Review. Sheryl Goss, MS, RT(R), RDMS, RDCS, RVT Reviewed by Catherine E. Rienzo, MS, RT(R), RDMS

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1 National Certification Exam Review Breast Sonography Sheryl Goss, MS, RT(R), RDMS, RDCS, RVT Reviewed by Catherine E. Rienzo, MS, RT(R), RDMS The SDMS has made every effort to ensure that the contributors to this publication are knowledgeable authorities in the specified specialty area(s). The SDMS highly recommends that readers review and study multiple publications on the specialty content areas and on test-taking strategies when preparing for National Certification Examination.

2 About the Society of Diagnostic Medical Sonography Founded in 1970, the Society of Diagnostic Medical Sonography (SDMS) is the largest professional association representing the interest of sonographers. Its mission is to promote, advance, and educate its members and the medical community in the science of diagnostic medical sonography in order to enhance the provision of patient care. SDMS embraces all specialties utilizing ultrasound for diagnostic medical purposes. ISBN Copyright All rights reserved by the Society of Diagnostic Medical Sonography, Plano, Texas. No part of this publication may be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.

3 Table of Contents Preface... 1 Abbreviations... 2 Module 1: Instrumentation and Techniques... 3 Introduction... 4 A. Instrumentation Transducers... 4 B. Image Optimization Overall gain Time gain compensation (TGC) Output power Dynamic range Harmonics Spatial compound imaging Automatic optimization Panoramic imaging Dual screen imaging Magnification... 7 C. Color Doppler and Power Doppler Imaging Usefulness Pressure Set-up... 8 D. Artifacts Beneficial artifacts Detrimental artifacts... 9 E. Examination Information Indications for breast sonography Contraindications... 9 F. Clinical Assessment Examination Patient history Prior studies Physical inspection and palpation G. Mammography Technique Mammographic projections Correlation of location Mammographic appearance Correlation of features H. Sonographic Technique Annotation Positioning Scan planes Transducer pressure Echo-palpation I. Magnetic Resonance Imaging General information Contrast enhanced imaging Lymph nodes Limitations and challenges Comparison of mammography, sonography, and MRI Module 1 Review Questions Module 2: Normal Anatomy Introduction A. Embryologic and Post Pubescent Breast Development Early mammary gland Thickness of the glandular tissue Hormonal stimulation Further development of the breast tissue Where the breasts develop B. Congenital and/or Developmental Variant Terminology Amastia Athelia Amazia Polymastia Polythelia... 24

4 6. Congenital nipple flattening or nipple inversion Unilateral early ripening C. Vasculature Arterial Venous D. Physiology and the Ductal System The main function of the breast Terminal duct lobular units (TDLU) Beneath the areola Duct tributaries Lactiferous duct lining Lactiferous duct size Lactiferous duct visualization E. Fibrous Planes Demonstration Sonographic appearance Integrity of the fibrous planes and disease F. Skin Composition Thickness Anteroposterior dimension Visualization G. Areolar Complex H. Nipple I. Premammary/Subcutaneous Fat Layer J. Superficial or Anterior Mammary Fascia K. Mammary Zone L. Deep or Retromammary Fascia M. Retromammary Space N. Musculature O. Ribs P. Lymph Nodes Flow of lymph Intramammary lymph nodes Axillary chain (primary chain) Secondary lymphatic chains and routes Q. Pregnancy-Induced Changes R. Involutional Changes Module 2 Review Questions Module 3: Benign vs. Malignant Features Introduction A. Terminology and Descriptors for Characterization of Breast Nodules Sharpness of margins Contour of margins Border thickness and echogenicity Shape and orientation Echogenicity Echo texture Effects on distal echoes Compressibility Vascularity Effects on fibrous planes Effects on ducts Calcifications Lymph nodes Skin thickening Elastography B. Interpretation Criteria Mammography Sonography Module 3 Review Questions Module 4: Benign Conditions and Pathology Introduction A. Simple Cyst B. Complex Cyst C. Sebaceous Cyst D. Epidermal Inclusion Cyst E. Fibrocystic Nodules F. Fibroadenoma... 56

5 G. Galactocele H. Intraductal Papilloma I. Intracystic Papilloma J. Lipoma K. Hamartoma L. Inflammation and Infection M. Juvenile Papillomatosis Histology Clinical presentation Sonographic appearance N. Mondor s Disease Thrombosis within superficial vein(s) of the breast Relatively rare in occurrence Etiologies Signs and symptoms Sonographic findings Differentiate from cyst or duct Sonographic technique consideration O. Traumatic Changes Traumatic fluid collections Hematoma Seromas Lymphocele Fat necrosis Postoperative scarring P. Radial Scars Module 4 Review Questions Module 5: Malignant Pathology Introduction: A. Breast Cancer Overview B. Noninvasive Carcinoma C. Invasive Ductal Carcinoma D. Invasive Lobular Carcinoma E. Medullary Carcinoma F. Colloid (Mucinous) Carcinoma G. Papillary Carcinoma H. Tubular Carcinoma I. Phyllodes (Phylloides) Tumor J. Primary Lymphoma K. Multifocal Multicentric Carcinoma L. Inflammatory Carcinoma M. Metastatic Disease Module 5 Review Questions Module 6: Breast Augmentation Introduction: A. Role of Imaging Modalities Mammography MRI Sonography B. Implant Locations Retroglandular placement (subglandular) Retropectoral placement (subpectoral) C. Types of Implants D. Complications E. Implant Rupture F. Artifacts G. Autologous Tissue Reconstruction Module 6 Review Questions Module 7: Male Breast Imaging Introduction: A. Anatomy B. Normal Sonographic Appearance C. Benign Disease Gynecomastia Lipoma Cyst D. Malignant Pathology Incidence... 95

6 2. Median age Risk factors Invasive ductal carcinoma Other malignancies E. Patient Care and Awareness Module 7 Review Questions Module 8: Invasive Procedures Introduction: A. Image Documentation B. Pathology Assessment Histology Cytology Histology versus cytology C. Invasive Procedures Cyst aspiration Fine needle aspiration Wire localization Core biopsy Vacuum-assisted biopsy Advanced Breast Biopsy Instrumentation Ductography Sentinel node procedure Potential complications Module 8 Review Questions References

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