Chapter 21 The Breast (WB)

cyst

A(n) __________aspiration can be performed to determine whether a lesion is complex cyst or truly a solid mass.

linguine

As the implant collapses and the membrane folds inward, a series of discontinuous echogenic lines parallel to the face of the transducer may be seen and are referred to as the "stepladder sign" or "__________ sign".

parallel

Benign lesions tend to grow within the normal tissue planes, and their long axis lies __________ to the chest wall.

mobile

Benign tumors are rubbery, __________, and well delineated (as seen in a fibroadenoma), whereas malignant tumors are often stone hard and irregular with a gritty feel.

irregular

Breast cancer is usually lobular or __________ in shape, uneven in surface contour (sometimes gritty in texture), and fixed or poorly movable.

ductal lobar noninvasive invasive

Breast carcinomas are generally categorized by two factors: where the cancer cells originate (__________ or __________) and whether the cancer is prone to spreading (__________ or __________).

menarche

Breast development begins before __________ and continues until the patient is approximately 16 years old.

fibrocystic condition

Clinical signs and symptoms of __________ include the lumps and pain that the patient feels that fluctuate with every monthly cycle. In most cases both breasts are equally involved.

axillary

Lymphatic drainage from all parts of the breast generally flows to the __________ lymph nodes.

vertical

Malignant lesions are able to grow through the connective tissue and may have a(n) __________ orientation when imaging the breast from anterior to posterior.

vascularity

Malignant masses will often demonstrate increased __________ within the lesion and often have a feeder vessel, which can be identified with careful evaluation.

acini

Milk is produced within the __________ and carried to the nipple by the ducts.

fibroadenomas

Most breast masses that arise during the adolescent years are __________.

terminal

Most cancer originates in the __________ ductal lobular units, whereas a smaller percentage originates in the glandular tissue.

intraductal

Older or postmenopausal women are more likely to have __________ papillomas, duct ectasia, and cancer.

menstrual cycle

Pertinent clinical information that should be provided by the referring physician includes size and location of the lump, when it was noticed, and its relation to the __________.

hypoechoic

The fatty tissue appears __________, where the ducts, glands, and supporting ligaments appear echogenic.

estrogen

The growth of a fibroadenoma is stimulated by __________.

prolactin

The hormone produced by the pituitary gland that stimulates the acini to produce and excrete milk is called __________.

mammary, thoracic

The main arterial supply to the breast comes from the internal __________ and the lateral ___________ artery.

horizontally

The normal tissue planes of the breast are __________ oriented.

oxytocin

The physical stimulation of suckling by the baby initiates the release of __________ (produced by the hypothalamus and released by the pituitary gland), which further incites prolactin secretion, stimulating additional milk production.

fluid

The primary function of the breast is __________ transport.

radial/antiradial

The use of the __________ positions is unique to the breast and can often pick up subtle abnormalities extending toward the nipple along the ductal system from the mass.

no internal echoes, smooth inner margins w/capsule, post acoustic enhancement

To be considered a simple cyst, a lesion must meet which three criteria on ultrasound?

differentiating

Ultrasound is also useful in __________ structures within uniformly dense breast tissue where mammography is limited (e.g., in differentiating solid, round masses from fluid-filled cysts and visualizing tissue adjacent to implants or other structures that limit visualization by mammography).

young, dense

Ultrasound may be used for screening purposes in __________ breasts that are __________ and difficult to penetrate by mammography, to evaluate palpable masses that are not visible on a mammogram, and to image the deep juxtathoracic tissues not normally visible by mammography.

fibrocystic condition

condition that represents different, essentially normal, tissue processes within the breast that in some patients become exaggerated to the point of raising concern for breast cancer

Cooper's ligaments

connective tissue septa that connect perpendicularly to the breast lobules and extend out to the skin

retromammary layer

deepest of the three layers of the breast noted on breast ultrasound

peau d'orange

descriptive term for skin thickening of a breast that resembles the skin of an orange

breast

differentiated apocrine sweat gland with a functional purpose of secreting milk during lactation

hyperechoic

echo texture that is more echogenic than the surrounding tissue

isoechoic

echo texture that resembles the surrounding tissue

spiculation

finger-like extension of a malignant tumor

cyst

fluid-filled sac of variable size

apocrine metaplasia

form of fibrocystic change in which the epithelial cells of the acini undergo alteration

acinus (acini)

glandular (milk-producing) component of the breast lobule

hypoechoic

having relatively weak echoes

gynecomastia

hypertrophy of residual ductal elements that persist behind the nipple in the male

breast cancer

involves two main types of cells (ductal and lobular)

mammary layer

middle layer of the breast tissue that contains the ductal, glandular, and stromal portions of the breast

fibroadenoma

most common benign solid tumor of the breast, consisting primarily of fibrous and epithelial tissue elements

subcutaneous layer

most superficial of the three layers of the breast identified on breast ultrasound

juxtathoracic

near the chest wall

lobular carcinoma in situ

neither considered a true cancer nor treated as such

tail of Spence

normal extension of breast tissue into the axillary region

adenosis

overgrowth of the stromal and epithelial elements of the acini within terminal ductal lobular unit (TDLU) of the breast

breast self-examination

part of breast cancer screening best done at the end of menses each month

clinical breast examination

part of breast cancer screening done by a health care provider

radial

plane of imaging on ultrasound of the breast

antiradial

plane of imaging on ultrasound of the breast that is perpendicular to the radial plane of imaging

breast cancer screening

preventive care that includes annual screening mammography (starting at age 40), monthly breast self-examination, and regular clinical breast examination

anechoic

without echoes

asymptomatic

without symptoms

round, oval

A dominant cyst is frequently __________ or __________ (long axis toward nipple), smooth, soft (some cysts under tension can be firm and are usually very tender), and easily movable.

benign, malignant

A rounded or oval shape is usually associated with __________ lesions, whereas sharp, angular margins are associated with __________ lesions.

intracapsular

A(n) __________ implant rupture occurs when there is a breach of the membrane surrounding an implant, but the silicone that leaks out is still confined within the fibrous scar tissue that forms a "capsule" around the implant.

milk

An important function during the reproductive years is for the breast to make __________ from nutrients and water taken from the bloodstream.

benign

An intraductal papilloma is a small, __________ tumor that grows within the acini of the breast.

in situ

Carcinomas that do not normally spread outside of the duct or lobule are called noninvasive, non-infiltrating, or __________ cancers, whereas cancers that spread into nearby tissue are said to be invasive or infiltrating.

progesterone

During pregnancy, acinar development is accelerated to enable milk production by estrogen, __________, and prolactin.

estrogen

During this time of development (menarche - age 16) , the ductal system proliferates under the influence of __________.

acini

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

echogenic

Fat is the least __________ tissue within the breast.

homogeneously solid

Fibroadenomas are usually similar in shape, but they are often quite firm and rubbery in consistency and __________ on ultrasound.

cancer

Full maturation of the acini occurs during lactation and is thought to be mildly protective against the development of breast __________.

height, width

If a mass measures longer in the anteroposterior dimension (__________) than in either transverse or sagittal planes (__________), the mass has vertical orientation that is usually described as being "taller than wide" and is suspicious for malignancy.

encapsulated

If the tumor is __________, it continues to grow in one area, compressing and distorting the surrounding architecture.

fibrotic

In __________ tissue, most cancer growth occurs along the borders.

fibrocystic

Lesions more common to younger women are __________ disease and fibroadenomas.

cancer

Skin dimpling or ulceration and nipple retraction nearly always result from __________.

subcutaneous mammary retromammary

Sonographically the breast is divided into three layers located between the skin and the pectoralis major muscle on the anterior chest wall. These layers are the __________ layer, the __________ layer, and the __________ layer.

hypoechoic

Sonographically, cancers can be difficult to differentiate in the fatty breast because most cancers appear __________ and can be difficult to differentiate from the normal breast tissue.

malignant

Sonographically, fat necrosis appears as an irregular, complex mass with low-level echoes, may minic a(n) __________ lesion, and may appear as fat, but is separate and different from the rest of the breast parenchyma.

pectoralis major

The __________ muscle lies posterior to the retromammary layer.

upper outer

The __________ quadrant of the breast contains the highest concentration of lobes.

ductal

The __________ system is critical in the transport of fluids within the breast.

adipose or fatty

The __________ tissue can situate itself in and among the areas of glandular tissue, and in some scanning planes it can mimic isoechoic or hypoechoic masses.

sweat

The breast is a modified __________ gland located in the superficial fascia of the anterior chest wall.

milk

The expulsion of the placenta after the birth of a baby causes a drop in circulating progesterone, initiating ___________ production within the breast.

age, risk factors, symptoms, location, clinical impression of breast lumps

What basic clinical information must the sonographer have for any patient referred for breast ultrasound?

lymphatics blood vessels

__________ and __________ are frequently used as pathways for new tumor development.

acute mastitis

__________ may result from infection, trauma, mechanical obstruction in the breast ducts, or from other conditions. It often occurs during lactation, beginning in the lactiferous ducts and spreading via the lymphatic or blood.

carcinoma

__________ refers to a breast tumor that arises from the epithelium, in the ductal and glandular tissue, and usually have tentacles.

malignancies

__________ tend to grow within the ducts and will often follow the ductal system in a radial plane, toward the convergence at the nipple.

atypical hyperplasia

abnormal proliferation of cells with atypical features involving the TDLU, with an increased likelihood of evolving into breast cancer

axilla

armpit

multicentric breast cancer

breast cancer occurring in different quadrants of the breast at least 5 cm apart

multifocal breast cancer

breast cancer occurring in more than one site within the same quadrant of the same ductal system of the breast

palpable

can be felt on clinical examination

infiltrating ductal carcinoma

cancer of the ductal epithelium; most common general category of breast cancer, accounting for approximately 85% of all breast cancers

infiltrating lobular carcinoma

cancer of the lobular epithelium of the breast, arises at the level of the TDLU

nonpalpable

cannot be felt on clinical examination

cyst aspiration

common diagnostic and interventional procedure that involves placing a needle through the skin of the breast into a cystic mass and pulling fluid out of the cyst through the needle

epithelial hyperplasia

proliferation (hyperplasia) of epithelial cells lining the terminal duct-lobular unit

fremitus

refers to vibrations produced by phonation and felt through the chest wall during palpation

sentinel node

represents the first lymph node along the axillary node chain

atypical lobular hyperplasia

shows some, but not all of the features of lobular carcinoma in situ

terminal ductal lobular unit (TDLU)

smallest functional portion of the breast involving the terminal duct and its associated lobule containing at least one acinus

Paget's disease

surface erosion of the nipple characterized by redness with flaking and crusting caused by direct invasion of the skin of the nipple by underlying breast cancer

lobular neoplasia

term preferred by many authors to replace LCIS and atypical hyperplasia

atypical ductal hyperplasia

the pathologist recognizes some, but not all, of the features of ductal carcinoma in situ

areola

the pigmented skin surrounding the breast nipple

breast imaging reporting and data system (BIRADS)

trademark system created by the American College of Radiology (ACR) to standardize mammography reporting terminology, categorize breast abnormalities according to the level of suspicion for malignancy, and facilitate outcome monitoring

diagnostic breast imaging

type of breast imaging examination that is more intensive than routine screening mammography