Breast Diagnostic Evaluation

Physical Inspection (done by nursing staff)- Bilateral breasts should be evaluated for: (7)

1. Size 2. Shape 3. Contour 4. Symmetry 5. Skin redness, edema, dimpling, protrusions, skin thickening 6. Nipple retraction 7. Discharge

What is the echogenicity of... 1. Skin layer? 2. Cooper's ligaments? 3. Glandular tissue? 4. Dense fibroglandular tissue? 5. Fibrous tissue (stromal)? 6. Ducts? 7. Muscle? 8. Veins/arteries? 9. Simple cysts? 10. Calcifications?

1. Skin - hyperechoic 2. Cooper's ligaments-hyperechoic 3. Glandular tissue-isoechoic to slightly hypoechoic 4. Dense fibroglandular tissue - hyperechoic 5. Fibrous tissue (stromal) - hyperechoic 6. Ducts - hypoechoic to anechoic 7. Muscle - hypoechoic 8. Veins/arteries-hypoechoic to anechoic 9. Simple cysts- anechoic 10. Calcifications - markedly hyperechoic

Other annotations to use for breast lesion imaging other than the main 4: (5)

1. Subareolar (SA) 2. Subclavicular 3. Lateral to the sternum 4. Axillary (AX) 5. Subaxillary

When using the echo-palpation technique, what is the difference between benign vs malignant masses?

Benign-moves slightly/mobile; Malignant-fixed.

In which screening mammogram view can evaluate if lesion is in anterior, mid, or posterior aspect of breast?

Both CC and MLO views

A system that provides universal reporting of mammographic findings.

Breast Imaging Reporting and Data System (BI-RADS)

Describe the 123 method for annotation:

Breast divided into 3 concentric rings (1,2,3) surrounding the nipple. 1: Lesion located near the nipple 2: Lesion is located mid distance from nipple 3: Lesion located in the periphery of the breast *Not as precise, subjective.*

Transmits beam in various directions, can decrease attenuation effects (shadowing); advantageous to see posteriorly (desmoplastic response, distance to chest wall).

Compound imaging

View where the breast tissue is compressed from superior to inferior and superimposed on a radiographic image.

Craniocaudal (CC) view

This technique is used to immobilize a mass between two fingers with one hand while opposite hand holding transducer slowly scans between the palpating fingers.

Echo-palpation

Why is the MLO view preferred to the ML view as a routine projection?

MLO because more of the breast tissue in UOQ and axilla is imaged (is not 90° to CC); ML loses tissue in the UOQ, where most cancers occur

Since a lesion may appear artificially displaced on the mammographic MLO view; For the sonographer, remember this acronym:

MULD (Medial Up, Lateral Down)

Option for optimization that is helpful for deep lesions and small superficial structures.

Magnification/Zoom (read/write)

What is the gold standard in breast screening studies?

Mammography

What is the true orthogonal (90°) view to the CC view?

Mediolateral (ML) view

View where the breast tissue is compressed from medial to lateral and superimposed on the radiograph.

Mediolateral Oblique (MLO) view

Avoid this artifact by angling the probe posterior to the nipple.

Nipple shadowing *Can also try rolling nipple to side.*

Is it possible to distinguish a cyst from solid lesion on mammography?

No

This knob determines intensity of the transmitted signal.

Output Power

_____ should be adjusted to allow simple cysts to be imaged free of artifactual echoes and distinguished from solid masses.

Overall Gain (amplification of receiver signal)

Option for optimization to demonstrate the relationship of lesion to nipple or the relationship of multiple lesions.

Panoramic imaging/extended field of view

Artifact: Reduced or absent echo amplitude deep to a structure; Associated with solid/malignant lesions.

Posterior Acoustic Shadowing

This knob provides for greater amplification of received signals from deeper tissue interfaces.

Time Gain Compensation (TGC) *Image should appear with a uniform echotexture throughout.*

Mammographic Appearance of Breast Tissue: *Radiolucent* Tissue type? Mammo appearance?

Tissue type: fat Mammo appearance: medium gray density

Mammographic Appearance of Breast Tissue: *Radiopaque* Tissue type? Mammo appearance?

Tissue type: fibrous glandular (fluid filled structures, solid lesions) Mammo appearance: lighter to white density

Describe the quadrant method for annotation:

Upper-Outer (UO) Upper-Inner (UI) Lower-Outer (LO) Lower-Inner (LI)

The ABC method for annotation directly correlates with the _____ of the sonographic image.

depth

It is difficult to pick up _____ breast cancers with ultrasound.

early - ductal carcinoma in situ (DCIS) *The goal for screening US to pick up early invasive cancer, not DCIS*

The thickness of the beam is determined by the manufacturer (transducer composition) in most linear transducers. What type of resolution does this describe?

elevational resolution

Contrast Resolution (GAIN settings) - all tissues and structures in the breast are relative to the medium gray shade of _____.

fat

Overall Gain (amplification of receiver signal) should be adjusted to allow _____ to appear as a medium level gray shade. All breast tissue should be compared to this layer.

fat

When using Doppler in breast ultrasound, keep box size narrow to enhance _____.

frame rate

Is the mammo and ultrasound appearance of the breast tissue homogeneous or heterogeneous?

heterogeneous (complex) *Varies!*

Sonographically look slightly _____ than location described on MLO mammographic view for a medial lesion.

higher

You should use the _____ frequency that allows penetration to chest wall.

highest

Because of the obliquity of the MLO view image and the nature of a radiographic image, lesions detected on _____ aspect of the breast may appear slightly higher on the MLO than actual location in breast.

lateral

The marker is always located in the _____ aspect of the breast on the CC view.

lateral

What is the ability to distinguish two points that lie side by side (perpendicular to beam)?

lateral resolution

In breast ultrasound, Doppler technique needs to be optimized for _____ (high/low) flow states.

low

When using Doppler in breast ultrasound, the PRF should be set _____(high/low) to ensure demonstration of flow, if present.

low

Sonographically look slightly _____ than location described on MLO mammographic view for a lateral lesion.

lower

Image optimization for breast ultrasound: If a single focus is used, then set at the reason of interest, or at or below _____ layer for general survey scanning.

mammary

Imaging sensitivity increases with a combination of _____ and _____ imaging modalities.

mammography and ultrasound

List the BI-RADS Categories (Number) and Diagnosis for each:

0 = incomplete 1 = negative 2 = benign 3 = probably benign 4 = suspicious abnormality (4A,B,C) 5 = highly suspicious of malignancy 6 = known biopsy proven malignancy

Image optimization for breast ultrasound: Use multiple focal zones with depth of ___-___cm between skin and chest wall.

0.5 to 5 cm

For a Screening Mammogram, what are the two pictures they acquire on each breast? What is the 3D option?

1. CC - Craniocaudal 2. MLO - Medial Lateral Oblique Another option: Tomosynthesis

Risk Factors for breast cancer: (6)

1. Gender 2. Patient Age 3. Family History 4. Personal History 5. Medications; especially hormones 6. Age menses began and age of menopause

How can you adjust the contrast resolution? (6)

1. Grey maps 2. Post processing 3. Focal zones 4. Auto optimize 5. Speckle reduction 6. Harmonics

Documentation of palpable masses should include: (8)

1. Location 2. Distance from nipple 3. Size 4. Shape (round, oval, lobular, irregular) 5. Notation when 1st observed 6. Progression over time 7. Consistency (soft, rubbery, firm, hard, gritty) 8. Mobility (movable, fixed)

Additional mammographic views part of a diagnostic workup: (4)

1. ML - Medial Lateral (straight lateral or 90° lateral) 2. XCCL - Exaggerated CC (Cleopatra) 3. RM / RL - Rolled Views 4. Valley View (cleavage view) *Other Special Views - spot compression, magnification, tangential.*

Why is mammography considered the best screening tool for the breast? (3)

1. Mammography is the most sensitive and accurate way of screening 2. Spatial resolution 3. The only modality for screening for early breast cancer

How can you adjust the temporal resolution? (4)

1. Number focal zones 2. Depth 3. Color Doppler 4. Field of view width

Clinical assessment prior to the sonogram include: (3)

1. Patient History 2. Bilateral Breast Inspection - document 3. Review of previous studies *Typically completed by RN if coming in for clinical concern. Mammo tech also makes note of general visual observations (dimpling, puckering, nipple inversion, nipple discharge) during screening mammograms.*

Breast Sonogram Artifacts: (7) *May be useful in determining the nature of a lesion.*

1. Posterior acoustic shadowing 2. Acoustic enhancement 3. Refractive shadowing 4. Grating lobes 5. Slice thickness 6. Reverberation 7. Nipple shadowing *Spatial compound imaging may reduce artifacts.*

Patient history questions for breast study include: (4)

1. Previous breast surgeries 2. Previous surgery and/or gyn disorders 3. Findings from monthly breast self-examination (BSE) 4. Findings from clinical breast examination (CBE) by a physician

4 Annotation methods to use in breast imaging:

1. Quadrant Method 2. Clock Method (Most commonly used labeling method) 3. 123 Method 4. ABC Method *Several methods reported based on physician/sonographer preference. Detailed annotation is helpful if follow-up examination is required.*

Mammographic Appearance of Breast Tissue: 3 Major tissue types (2 major radiographic densities "+ 1")

1. Radiolucent 2. Radiopaque 3. Micro- and Macro- Calcifications (Markedly Radiopaque)

Indications warranting the breast sonogram include... (3)

1. Repeat: mass, asymmetry, distortion 2. Clinical workup: lump, pain, discharge, thickening, etc. 3. Screening

Harmonics reduces artifactual echoes: (4)

1. Reverberations 2. Artifactual noise in anechoic structures 3. Grating/side lobes 4. Haze

_____ is excellent at detecting microcalcs and has better sensitivity, whereas _____ is better at specifying whether a mass is cystic vs. solid.

mammography; ultrasound

Fremitus may help identify _____ of a lesion.

margins *Tissues surrounding lesion vibrate and create signal/color. Lesion itself will not create a signal.*

Lesions in the _____ breast will appear slightly lower on MLO than actual location in breast.

medial

The craniocaudal (CC) view describes the location of a lesion _____ or _____ in comparison to the nipple.

medial or lateral

Echo-palpation provides real-time scanning with palpation; It is useful in assessing the _____ of a lesion.

mobility *Ensure visualization of correct structure.*

Fremitus can help differentiate normal vs. abnormal tissue. If color is present, is that a real mass or not a real mass?

not a real mass *Not effective differentiating benign/malignant mass.*

Breast Sonography is extremely _____ dependent.

operator *Both technique and image optimization are critical.*

Documentation should include any _____; should be indicated whether sporadic, constant, or cyclic in nature; diffuse or point specific.

pain/tenderness

Location of mammo lesion must be correlated with location of lesion on _____.

ultrasound

The BI-RADS classification system identifies four levels of breast density in keeping with relative increases in the amount of levels of fibroglandular tissue and their masking effects. These are:

1. The breasts are almost entirely fatty 2. There are scattered areas of fibroglandular density 3. The breasts are heterogeneously dense, which could obscure small masses 4. The breasts are extremely dense, which lowers the sensitivity of mammography

What are two reasons why patients would have a screening breast ultrasound instead of the typical screening mammography?

1. dense breast tissue 2. inability to tolerate mammo (consider functional state and age of patient)

Disadvantages to MRI screening: (4)

1. expensive 2. time consuming 3. may not demonstrate rapid washout typical of malignant lesions 4. not good at detecting calcifications

In general, sonography displays: 1. fatty tissue as _____ echoes. 2. glandular tissue as _____ to _____ echoes. 3. dense fibroglandular tissue as _____ echoes.

1. medium level gray 2. isoechoic to slightly hypoechoic 3. mildly hyperechoic *Therefore, fatty tissue is no more easily evaluated by sonography than the glandular tissue.*

For better lateral resolution... 1. wide or narrow beam? 2. few or multiple focal zones? 3. high or low frequency? 4. high or low line density?

1. narrow beam 2. multiple focal zones 3. high frequency 4. high line density

What is the patient position ultrasound techs to use if... 1. Medial region of interest? 2. Lateral region of interest? 3. Central region of interest? 4. Lesion is palpation dependent? 5. When lesion visualized on only the CC view?

1. supine 2. oblique or near decubitus 3. supine or possible decubitus 4. let the patient tell you (depends) 5. sitting or upright *Remember: Ipsilateral arm above head.*

_____ method describes approximate distance from nipple; _____ method describes the depth of a lesion.

123 method; ABC method

Clock Method: Holding the transducer sagittally on either breast above the nipple. What is the position?

12:00 position

In breast imaging, multiple focal zones (___-___) with adjustable placement preferred.

3-4 focal zones *frame rate is not a huge concern in breast imaging.*

In the mediolateral oblique (MLO) view, a ___° to ___° obliquity is utilized.

30° to 60°

Clock Method: Transducer in transverse plane of the lateral left breast. What is the position?

3:00 position

Clock Method: Holding the transducer sagittally on either breast below the nipple. What is the position?

6:00 position

For optimal focus in elevational plane (depth of 1.5 cm), ___-___MHz transducer must be used.

7-12 MHz *If lower frequency transducers used, focus placed too deep for breast imaging. Result: slice thickness artifact.*

Clock method: Transducer in transverse plane of the lateral right breast. What is the position?

9:00 position

According to the American College of Radiology (ACR), you should not use <___MHz center frequency for breast ultrasound.

<12 MHz

Artifact: Increased echo amplitude deep to a structure; Generally associated with a cystic/benign lesion.

Acoustic enhancement

What is the scan plane 90° to the radial plane?

Antiradial

What can you optimize to demonstrate an inflamed vs non-inflamed process/ Intraductal papillomas vs. inspissated secretions?

Doppler

Use _____ to prove the anatomic landmark for intramammary lymph node.

Doppler- blood flow in hilum

When the cells that line the milk ducts of the breast have become cancer, but they have not spread into surrounding breast tissue.

Ductal carcinoma in situ (DCIS)

This knob improves imaging by adding more shades of gray and contrast variability; Aids in the demonstration of subtle tissue differences.

Dynamic Range

Intramammary structures should be assessed for compressibility by using varying degrees of pressure. How will fatty vs neoplastic tissue vary with compression?

Fatty tissue is easily compressed; Neoplastic tissue has a firmer consistency with little or no compressibility

What is the term for vibration of the chest wall while using power Doppler and having the patient hum or say "ee" for as long as he/she can?

Fremitus

Artifact: Secondary off-axis concentrations of energy not parallel to the central beam axis; Can display echoes within a cyst.

Grating lobe

Echoes received at twice the frequency of transmitted frequency; Improves signal to noise ratio.

Harmonics *Remember ultrasound's limitations of penetration and resolution.*

_____ means something contains many different items and has many different variations; With respect to breast density it implies that the fibrous tissue is prevalent throughout the breast, but not clustered together.

Heterogeneous

What type of transducer should you use for breast ultrasound? Frequency?

Linear array (9-15 MHz)

What is the scan plane goes from the periphery of the breast to the nipple; It follows the ductal system; (think spokes of a wheel, hands of a clock)?

Radial

Describe the ABC method for annotation:

Region A: represents a lesion closest to the skin surface B: mid way in the breast C: closest to the chest wall

For the ABC method for annotation, which region is probably within the mammary zone?

Region B

Artifact: Linear echoes parallel to a strong interface; Found in the near field.

Reverberation *Occurs with implants.*

A lesion or any area of the breast should be viewed in what two perpendicular projections (orthogonal planes)? One view is insufficient.

Sagittal and transverse/ Radial and antiradial (preferred)

What is the difference between a screening breast ultrasound and a diagnostic breast ultrasound?

Screening- patient is asymptomatic; age 40 or over. Diagnostic- these patients are symptomatic or are recalled because of abnormal screening mammogram. *Same day results.*

What's the difference between Grating lobes and Side Lobes?

Side Lobes (refractive edge shadowing): Refraction of the beam when it encounters a curved surface. It is Nonspecific in determining benign versus malignant. Grating Lobes: Off axis concentrations of energy. Causes artifactual echoes within a cyst and is reduced with harmonic imaging.

Artifact: The beam has a finite width that reflectors lying to the side of the central beam axis can be detected by the ultrasound system and is displayed as if they lie on axis; Can display echoes within a cyst.

Slice thickness

Option for optimization to show both radial and antiradial images besides each other.

Split screen imaging

Axillary view that provides better imaging of the lateral portion of breast to the axillary tail.

XCCL (Exaggerated CC)

When using Doppler in breast ultrasound, use minimal pressure, to avoid vessel _____.

ablation

Increase/decrease of _____ of returned echo of specific areas by moving TGC's left or right.

amplification

What is the ability to distinguish two points as separate in space that are parallel to path of beam?

axial resolution

Are malignant or benign masses soft and compressible?

benign

Does a mass that is wider than tall suggest a malignant or benign nature?

benign

Images representing your general survey of a targeted area and of any findings must show _____; Can then optimize depth, etc. for findings.

chest wall

When scanning breast, the transducer should be placed perpendicular to _____ for a more uniform production of echoes.

chest wall

If the patient had a previous mammo or ultrasound study, the prior study needs to be reviewed by the sonographer for...

comparison with the current study

Moderate _____ will improve detail, decrease the depth of tissue that the sound beam must pass through, and improve artifact differentiation.

compression

If you only scan in longitudinal and transverse planes for breast ultrasound imaging, _____ can be missed.

projections *Subtle projections can be missed or appear oval, round, or minimal borders lobulations resulting in misclassification as probably benign.*

All solid lesions should be scanned in the _____ and _____ planes; subtle _____ that course toward the nipple or branch outward in the breast can be demonstrated.

radial and antiradial; projections

In general, mammography displays fatty tissue as _____ (transparent and easily penetrated by the x-ray beam), and dense fibroglandular tissue as _____ (impenetrable to the x-ray beam).

radiolucent; radiopaque

Mammographic Densities: _____ tissues typically offer greater diagnostic information and _____ tissues may prohibit diagnostic information.

radiolucent; radiopaque

Cooper's ligaments create artifactual _____ with improper pressure!

shadowing

What happens to a mass when compression is applied?

shows a < AP dimension

It is essential that _____, _____, and _____ of specific lesions are consistent on mammography and sonography.

size, shape, and density *Be cautious in describing an incidental finding as the cause of a mammographic abnormality when size, shape, and density are not consistent.*

For breast ultrasound, output power settings should be set so penetration and echo amplitude are optimized from the _____ to _____.

skin to chest wall

Blood flow confirms that a lesion is _____.

solid *absence of flow, however, may not confirm a cystic lesion.*

What is the ability to distinguish two points as separate in space?

spatial resolution

Use _____ or _____ for lesions closest to transducer to place in targeted elevation focal area. *1 cm or less is recommended.*

standoff pads or gels

The mediolateral oblique (MLO) view estimates the proximity of a lesion _____ or _____ in comparison to the nipple.

superior or inferior

Annotations should include any previous _____ and _____; should be mapped, dated, and histologic findings recorded.

surgeries and scars *History of scars is important (ugly on ultrasound), histologic findings indicate high risk lesions, etc.*

What is the ability to resolve targets in motion?

temporal resolution *not as imperative in breast since breast relatively immobile during study.*

MLO view is difficult to compare to the longitudinal view on US due to...

the obliquity used on the mammo

Why is the radial plane preferred over the sagittal plane when scanning breasts?

the radial plane more accurately follows the ductal system of the breast.

CC view is comparable to the _____ view on ultrasound.

transverse