Breast Ultrasound_Scanning Protocol & Sonographic Findings - Presentation.

BREAST ULTRASOUND: SCAN PROTOCOL & SONOGRAPHIC FINDINGS VITAL PROJECT PART B – MODULE 3– PRESENTATION 1 AIHE Radiology Across Borders Australian Institute of Healthcare Education Unrestricted .org SONOGRAPHIC APPEARANCE Sonographic appearance depends on: uAge uFunctional state of breast There are 3 layers to the breast: ① Subcutaneous layer ② Mammary layer ③ Retromammary layer AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Subcutaneous Layer ① Most anterior layer ② Skin echogenic • ③ Anterior Connective Tissue echogenic • ④ Fat Lobules Hypoechoic relative to the skin & connective tissue • Skin line Subcutaneous layer Mammary layer Retromammary layer Retromammary muscle Pectoralis major muscle Mammary Layer ① Contains the glandular tissue & breast parenchyma ② Medium level to low level echogenicity ③ Fat is seen between the parenchymal elements & is hypoechoic to surrounding parenchymal breast tissue ④ Ducts & ductules are anechoic tubular structures ⑤ Coopers ligaments increased echogenicity and bright linear echoes ⑥ Glandular / parenchymal tissues are homogeneous in texture ⑦ Varies in appearance according to age and breast function AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Mammary Layer SKIN SCF PREMAMMARY ZONE CL MAMMARY ZONE FGT RETROMAMMARY ZONE RMF PM G PAR 5.0 12.0 Copyright @ 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Cooper’s Ligament P p R 5.0 10.0 BREAST TISSUE Copyingh: @ 2012. 2000. 2001. 1905. 1880. 1963. 1978 by Mosby. am mprint o Elsevier Cooper’s ligament is echogenic within subcutaneous layer AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Younger Breast ① Higher % of parenchyma compared to fat % ② Dense echogenic pattern ③ Difficult on mammography AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org P PAR 5.0 12.0 Copyright 0 2012. 2008, 2001, 1995. 1988, 1983, 1978 by Moshy an imprint of Elsevier Inc. Mammary-glandular layer lies between the subcutaneous fatty layer anteriorly and the retromammary layer posteriorly (arrows). AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org FR 42Hz AGC M3 RS 2D P 48% C 64 P Med Res TAC1 X Rt Breast 12 OClock 4.0- AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Pregnant or Lactating Breast 6cm 13M12L BREAST FROZEN ① Larger and denser glandular portions 41G 72DR E2 MD* . A2 ② Less echogenic interfaces RT BT RAD 11_ B AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Mature Breast ① Mammary layer atrophies and occupies a smaller % of overall breast size ② Gradually replaced by fatty tissue AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Skin line Subcutaneous fat and connective tissue layer Glandular mammary layer Retromammary fat and connective tissue layer Pectoralis muscle AIHE RAB Radiology Australian Institute of Healthcare Education Across Borders .org -Skin line Subcutaneous fat Cooper's ligaments Pectoralis muscle AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Retromammary Layer ① Similar in size and appearance to the subcutaneous layer ① Bordered posteriorly by the pectoralis major muscle üHypoechoic in comparison with adjacent structures ② Ribs üHyperechoic rounded structures üDense posterior shadowing AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org O Subcutaneous layer Mammary layer Retromammary layer Pectoralis muscle P R 5.0 12.0 BREAST TISSUE SonoCT / XRES IMAGING AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Nipple ① Ovoid hypoechoic structure ② Posterior shadowing if scanning directly over it ③ Slight angling around the nipple will display the tissue posterior to the nipple Nipple NIPPLE AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Areolar ① Hyperechoic but slightly lower echogenicity than skin ② Lactiferous ducts hypoechoic tubular structures converging towards the nipple Skin line Subcutaneous fat Ducts Breast parenchyma AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Normal Intramammary Lymph Node cortex Chilum Long axis 8.5 x 6 mm Short Axis IM Node Copyright @ 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Lactating Breast LT LT BREAST RADIAL 0700 Copyright @ 2013 Wolters Kluwer Health | Lippincott williams & Wilkins AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Take Note: Is the overall sonographic appearance consistent: ① Throughout each breast? ② Between the two breasts? AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org SCAN TECHNIQUE AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Indications for Examination Palpable mass • Ø In breast / axilla Breast pain • Correlation with mammogram • Inflammation of breast (red, thickened or swollen skin) • Skin dimpling or retraction • Nipple changes • Ø Irritation, discharge, bleeding, lump, discolouration, nipple inversion PHx Breast ca or FHx Breast ca • Guidance to interventional procedures • Screening of high risk patients • Dense young breasts • Lactating patients • Pregnant patients • Trauma • AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Skin dimpling Retracted signs Edema of skin Nipple retraction (Peau d'orange sign) and deviation Abnormal contours (A) Carcinoma of breast AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Check the Patient History 1 Family history 2 Previous mammograms 3 Masses 4 Scars 5 Skin changes 6 Nipple discharge 7 Breast contour 8 Age 9 Parity / Gravida / Aborta 10 Medications (hormones) 11 Breast surgery / radiotherapy AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Risk Factors for Malignancy 1 Female gender 2 Increasing age 3 Family or personal history of breast cancer 4 Premenopausal breast cancer 5 Associated cancers (ovarian, colon, prostate) 6 Biopsy-proven atypical proliferative lesions 7 Lobular neoplasia (lobular carcinoma in-situ) 8 Atypical epithelial hyperplasia 9 Prolonged estrogen effect 10 Early menarche 11 Late menopause 12 Nulliparity 13 Late first pregnancy AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Contraindications / Limitations ① Patient obesity ØMay need to adjust the frequency ① Post surgical ØNeed to adjust the scan technique AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Room Preparation Machine Preparation Transducer Preparation == üUse the highest frequency possible at all times and the appropriate footprint for the Aguasonit 100 examination to be undertaken üMore than one transducer may be required to complete an examination AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Transducer Specific High frequency linear array • ØUp to 17 MHz Breast Preset • AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Patient Consent ① Provide an explanation of the examination ② Ensure patient privacy is maintained ③ Check if patient requires a chaperone ④ Obtain informed patient consent AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Patient Preparation & Position ① Remove upper clothing, including bra ② Provide a gown that opens at the front or drape a towel across the chest until ready ③ Patient is supine on couch / or slightly rotated to have the side being examined raised with a 45 degree wedge underneath the raised side ü The aim is to spread the breast tissue out evenly ü Reduces depth of the breast tissue ④ Place ipsilateral arm above head ⑤ Place gel on the breast area AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Clinical Examination Breast examination (for palpable mass) üLocation of mass üClock face or quadrant üCharacteristics of mass üSize üShape (round, oval, lobular, irregular) üSurface contour (smooth, irregular) üConsistency (soft, rubbery, firm, hard, gritty) üMobility (movable, fixed) AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org PROTOCOLS FOR BREAST SCANNING AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Survey Scan ① Perform a survey scan of the entire breast and axilla & nipple & areola ØRadial & Anti-radial ØLongitudinal & transverse ② The transducer needs to be perpendicular to the skin surface at all times ØMay need to rock the transducer to keep it perpendicular ③ Must scan in at least 2 planes AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Protocol 1: Clock Method ① Imaging the breast is a clock face ② Scan with the transducer in a radial Radial pattern around the nipple ③ Parallel to the ductal system Anti radial AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Protocol 1: Clock Method ØTransducer starts at 12 O’clock with notch facing nipple ØScan around the nipple by rotating the transducer from 12 – 3 – 6 O’clock ØAt 6 O’clock reorientate the transducer so the right edge of the of the transducer is in contact with the nipple (notch is facing away from transducer) ØContinue in a clockwise direction towards 9 and 12 O’clock ØLarge breast may need to rotate around again in the outer zone of the breast AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Protocol 1: Clock Method ØNext scan the breast in the anti-radial plane Ø90 degrees to the radial plane ØPerpendicular to the ductal system ØPlace transducer at 12 O’clock position in antiradial position at outer margin of breast ØMove transducer from outer aspect towards the nipple ØMove to 1 O’clock position and report ØContinue around the nipple until return to 12 O’clock AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org VL AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Measurements are taken from the nipple RT LT 1 o clock 5cm FN 10 o clock 4cm FN AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Protocol 2: Quadrant Method Splits the breast into 4 quadrants per breast Right Side: Axillary Right upper outer quadrant (RUOQ) 12 o'clock • process Supero- Right upper inner quadrant (RUIQ) • Supero- ~60% ~15% medial lateral Areola Right lower outer quadrant (RLOQ) Nipple • 9 3 Right lower inner quadrant (RLIQ) Infero- Infero- • lateral ~10% ~5% medial Left Side LUOQ, LUIQ • Right breast 9 LLOQ, LLIQ FIGURE B1.5. Breast quadrants. • AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Protocol 2: Quadrant Method ØUse a grid method and survey the entire breast systematically in longitudinal and transverse ØEnsure overlap between each pass AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org = AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org = AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org = AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org = AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org = AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org = AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Protocol 3: Targeted Exam ØIf an abnormality is detected on a mammogram may request a targeted scan ØMust image and document the area of concern Radial & anti-radial planes • or Longitudinal & transverse plane • 3 measurements L x W x H • Colour & power Doppler of any pathology • AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Axilla Scan ØPlace the transducer in a longitudinal plane over the superomedial aspect of the axilla ØNotch to point superiorly ØSlide transducer from supermedial to superolateral aspect and then inferiorly from the inferiolateral to inferiomedial aspect & continue until the entire axilla insonated to overlap with the upper outer quadrant AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Axilla Scan Rotate to transverse and scan from superiomedial to inferio medial aspect and then back to inferiolateral to superiolateral aspect AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org LT BREAST - 12 O’clock (radial) FR 43Hz M4 RS 2D P 71% C 79 P High Res TAC1 Lt Breast 12 O'clock 3.0- AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org LT BREAST 3 O’clock (radial) FR 43Hz M4 RS 2D 73% C 79 P High Res TAC1 Lt Breast 3 0' clock 3.0- AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org LT BREAST 6 O’clock (radial) FR 43Hz M4 RS 2D 73% C 79 P High Res TAC1 Lt Breast 6 O'clock 3.0- AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org LT BREAST 9 O’clock (radial) FR 43Hz M4 RS 2D 73% C 79 P High Res TAC1 Lt Breast 9 O'clock 3.0- AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org LT BREAST NIPPLE FR 43Hz AGC M4 RS 2D P 81% C 79 P High Res TAC2 Lt Breast Nipple Long 3.0- AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org LT AXILLA FR 40Hz M4 RS 2D P 82% C 79 P High Res TAC1 X Lt Breast Axilla 3.5* AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Same series to be taken for right breast Right breast mass at 12:00 Right breast mass at 8:00 Left breast mass at 3:00 Sagittal (longitudinal) Sagittal (longitudinal) Sagittal (longitudinal) Transverse O Transverse Transverse Radial Antiradial Antiradial Radial Antiradial Radial Copyright @ 2012. 2008, 2001, 1005, 1989, 1983, 1978 by Mosby, an imprint of Elsevier Inc. TROUBLESHOOTING AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Nipple & Areolar Area ① Use additional gel ② Use gently pressure ③ Oblique planes & angling of transducer under the nipple ④ Stand off pad AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Large Breast ① May need lower frequency linear array transducer for penetration ② Radial scanning may be difficult as transducer not long enough to cover entire breast ③ Scan from nipple outwards in a series of circles towards the outer margins of the breast AIHE Radiology Across Borders Australian Institute of Healthcare Education .org Breast Augmentation ① Reverberation artefact Adjust controls appropriately • ② Variable composition Saline • Silicon • ③ Variable location Retromammary layer • Submuscular layer (beneath the pectoral muscle) • AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Post Surgical Scar ① Angle around the wound ② Additional gel may be needed if uneven skin surface remains after surgery ③ Consider MRI (if accessible) AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org Disclaimer All information provided by Radiology Across Borders is of general educational nature and does not consider the specific context of a particular patient case. Any information in this presentation is not intended as medical advice used in the diagnosis or treatment of a particular patient. Although we take all reasonable steps to provide accurate and evidence-based information, Radiology Across Borders cannot provide any warranties in relation to the contents of this presentation. Any questions? Contact us at info@radiologyacrossborders.org AIHE RAB Radiology Across Borders Australian Institute of Healthcare Education .org