Ebook Textbook of diagnostic sonography (7th edition): Part 1

(BQ) Part 1 book Textbook of diagnostic sonography presents the following contents: Foundations ofsonography; introduction to physical findings, physiology and laboratory data; essentials of patient care for the sonographer; ergonomics and musculoskeletal issues in sonography,...

SEVENTH EDITION VOLUME ONE TEXTBOOK OF DIAGNOSTIC SONOGRAPHY Sandra L Hagen-Ansert, MS, RDMS, RDCS, FASE, FSDMS Cardiology Department Supervisor, Echo Lab Scripps Clinic—Torrey Pines, California with 3,463 illustrations 3251 Riverport Lane St Louis, Missouri 63043 TEXTBOOK OF DIAGNOSTIC SONOGRAPHY   ISBN: 978-0-323-07301-1 Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Previous editions copyrighted 2006, 2001, 1995, 1989, 1983, 1978 Publisher: Andrew Allen Executive Editor: Jeanne Olson Developmental Editor: Linda Woodard Publishing Services Manager: Julie Eddy Project Manager: Richard Barber Design Direction: Paula Catalano Working together to grow libraries in developing countries Printed in the United States Last digit is the print number: 9  8  7  6  5  4  3  www.elsevier.com | www.bookaid.org | www.sabre.org To my daughters, Becca, Aly, and Kati, who are changing the world one day at a time CONTRIBUTORS Joan Baker, MSR., RDMS, RDCS President, Sound Ergonomics Kenmore, Washington Carolyn Coffin, MPH, RDMS, RDCS, RVT CEO, Sound Ergonomics Kenmore, Washington Marveen Craig, RDMS Diagnostic Ultrasound Consultant Tucson, Arizona M Robert De Jong, RDMS, RDCS, RVT Radiology Technical Manager, Ultrasound The Russell H Morgan Department of Radiology and Radiological Science The Johns Hopkins Hospital Baltimore, Maryland Terry J DuBose, MS, RDMS Associate Professor and Director Diagnostic Medical Sonography Program University of Arkansas for Medical Sciences Little Rock, Arkansas Pamela Foy, M.S., RDMS Clinical Instructor, Department OB/ GYN The Ohio State University Medical Center Columbus, Ohio Candace Goldstein, BS, RDMS Sonographer Educator Scripps Clinic Carmel Valley San Diego, California Charlotte G Henningsen, MS, RT (R), RDMS, RVT Chair and Professor Diagnostic Medical Sonography Department Florida Hospital College of Health Sciences Orlando, Florida Mira L Katz, PhD, MPH Associate Professor Division of Health Behavior and Health Promotion School of Public Health The Ohio State University Columbus, Ohio Fredrick Kremkau, PhD Professor & Director Center for Medical Ultrasound Wake Forest University School of Medicine Winston-Salem, North Carolina Salvatore LaRusso, MEd, RDMS, RT (R) Technical Director Penn State Hershey/ Hershey Medical Center Department of Radiology Hershey, Pennsylvania Daniel A Merton, BS, RDMS Technical Coordinator of Research The Jefferson Ultrasound Research and Educational Institute Thomas Jefferson University Philadelphia, Pennsylvania Carol Mitchell, PhD, RDMS, RDCS, RVT, RT(R) Quality Assurance Coordinator, UW AIRP Program Director, University of Wisconsin School of Diagnostic Medical Ultrasound University of Wisconsin Hospitals & Clinics Madison, Wisconsin Cindy A Owen, RT, RDMS, RVT Global Luminary and Research Manager Radiology & Vascular Ultrasound GE Healthcare Memphis, Tennessee Mitzi Roberts, BS, RDMS, RVT Chair, Assistant Professor Diagnostic Medical Sonography Program Baptist College of Health Science Memphis, Tennessee Jean Lea Spitz, MPH, RDMS Maternal Fetal Medicine Foundation Nuchal Translucency Quality Review Program Oklahoma City, Oklahoma Susan Raatz Stephenson, MEd, BSRT-U, RDMS, RT(R)(C) International Foundation for Sonography Education & Research AIUM communities.org Sandy, Utah Diana M Strickland, BS, RDMS, RDCS Clinical Assistant Professor and Co-Director Ultrasound Program Department of Obstetrics and Gynecology Brody School of Medicine East Carolina University Greenville, North Carolina Shpetim Telegrafi, M.D Assistant Professor Director, Diagnostic Ultrasound NYU School of Medicine, Department of Urology New York City, New York Barbara Trampe, RN, RDMS Chief Sonographer Meriter/University of Wisconsin Perinatal Ultrasound Madison, Wisconsin vii viii CONTRIBUTORS Barbara J Vander Werff, RDMS, RDCS, RVT Chief Sonographer University of Wisconsin-Madison Hospitals and Clinics Madison, Wisconsin Kerry Weinberg, MS, RDMS, RDCS Director Diagnostic Medical Sonography Program New York University New York, New York Ann Willis, MS, RDMS, RVT Assistant Professor, Diagnostic Medical Sonography Program Baptist College of Health Sciences Memphis, Tennessee Dennis Wisher, BS, RDMS, RVT Director of Education and Product Management Medison America, Inc Cypress, California REVIEWERS Jan Blend, MS, RT(R), RDMS, ARDMS Program Coordinator, Diagnostic Medical Sonography El Centro College Dallas, Texas Marianna C Desmond, BS, RT(R), RDMS Clinical Coordinator, Diagnostic Medical Sonography Program Triton College River Grove, Illinois Katherine K Borok, BS, RDMS, RDCS Clinical Coordinator American Institute of Ultrasound in Medicine Laurel, Maryland Jann Dolk, MA, RT(R), RDMS Adjunct Faculty, Diagnostic Medical Sonography Program Palm Beach State College Palm Beach Gardens, Florida Joie Burns, MS, RT(R)(S), RDMS, RVT Associate Professor, Program Director, Diagnostic Medical Sonography Boise State University Boise, Idaho Saretta C Craft, MS, RDCS, RVT Program Director, Diagnostic Sonography St Catharine College St Catharine, Kentucky Laura L Currie, BS, RT(R), RDMS, RVT Clinical Coordinator Cape Fear Community College Wilmington, North Carolina Ken Galbraith, MS, RT(R), RDMS, RVT State University of New York Syracuse, New York Kasey L Moore, ARRT, RDMS, RT(R) (M) (RDMS) Sonography Instructor Danville Area Community College Danville, Illinois Susan M Perry, BS, ARDMS Program Director, Diagnostic Medical Sonography Owens Community College Toledo, Ohio Kellee Ann Stacks, BS, RTR, RDMS, RVT Program Director, Medical Sonography Cape Fear Community College Wilmington, North Carolina Karen M Having, MS Ed, RT, RDMS Associate Professor, School of Allied Health Southern Illinois University-Carbondale Carbondale, Illinois Bridgette Lunsford, BS, RDMS, RVT Adjunct Faculty, George Washington University Washington, D.C ix PREFACE INTRODUCING THE SEVENTH EDITION The seventh edition of Textbook of Diagnostic Sonography continues the tradition of excellence that began when the first edition published in 1978 Like other medical imaging fields, diagnostic sonography has seen dramatic changes and innovations since its first experimental days Phenomenal strides in transducer design, instrumentation, color-flow Doppler, tissue harmonics, contrast agents, and 3D imaging continue to improve image resolution and the diagnostic value of sonography The seventh edition has kept abreast of advancements in the field by having each chapter reviewed by numerous sonographers currently working in different areas of medical sonography throughout the country Their critiques and suggestions have helped ensure that this edition includes the most complete and up-to-date information needed to meet the requirements of the modern student of sonography Distinctive Approach This textbook can serve as an in-depth resource both for students of sonography and for practitioners in any number of clinical settings, including hospitals, clinics, and private practices Care has been taken to cultivate readers’ understanding of the patient’s total clinical picture even as they study sonographic examination protocol and technique To this end, each chapter covers the following: • • • • • • • • • Normal anatomy (including cross-sectional anatomy) Normal physiology Laboratory data and values Pathology Sonographic evaluation of an organ Sonographic findings Pitfalls in sonography Clinical findings Differential considerations The full-color art program is of great value to the student of anatomy and pathology for sonography Detailed line drawings illustrate the anatomic information a sonographer must know to successfully perform specific sonographic examinations Color photographs of gross pathology help the reader visualize some of the pathology presented, and color Doppler illustrations are included where relevant To make important information easy to find, key points are pulled out into numerous boxes; tables throughout the chapters summarize the pathology under discussion and break the information down into Clinical Findings, Sonographic Findings, and Differential Considerations Sonographic findings for particular pathologic conditions are always preceded in the text by the following special heading:   Sonographic Findings.  This icon makes it very easy for students and practicing sonographers to locate this clinical information quickly Study and review are also essential to gaining a solid grasp of the concepts and information presented in this textbook Learning objectives, chapter outlines, comprehensive glossaries of key terms, full references for cited material, and a list of common medical abbreviations printed on the back inside cover all help students learn the material in an organized and thorough manner Scope and Organization of Topics The Textbook of Diagnostic Sonography is divided into eight parts: Part I introduces the reader to the foundations of sono­ graphy and patient care and includes the following: • Basic principles of ultrasound physics and medical sonography • Terminology frequently encountered by the sonographer • Overview of physical findings, physiology, and laboratory data • Patient care for the sonographer • Ergonomics and musculoskeletal issues for practitioners • Basics of other imaging modalities • Image artifacts Part II presents the abdomen in depth The following topics are discussed: • Anatomic relationships and physiology • Abdominal scanning techniques and protocols • Abdominal applications of ultrasound contrast agents • Ultrasound-guided interventional techniques • Emergent abdominal ultrasound procedures • Separate chapters for the vascular system, the liver, gallbladder and biliary system, pancreas, gastrointestinal tract, urinary system, spleen, retroperitoneum, and peritoneal cavity and abdominal wall Part III focuses on the superficial structures in the body including the breast, thyroid and parathyroid glands, scrotum, and musculoskeletal system xi xii PREFACE Part IV explores sonographic examination of the neonate and pediatric patient Part V focuses on the thoracic cavity and includes: • Anatomic and physiologic relationships within the thoracic cavity • Echocardiographic evaluation and techniques • Fetal echocardiography Part VI comprises four chapters on extracranial and intracranial cerebrovascular imaging and peripheral arterial and venous sonographic evaluation Part VII is devoted to gynecology and includes the following topics: • Normal anatomy and physiology of the female pelvis • Sonographic and Doppler evaluation of the female pelvis • Separate chapters on the pathologic conditions of the uterus, ovaries, and adnexa • Updated chapter on the role of sonography in evaluating female infertility Part VIII takes a thorough look at obstetric sonography The following topics are discussed: • The role of sonography in obstetrics • Clinical ethics for obstetric sonography • Normal first trimester and first-trimester complications • Sonography of the second and third trimesters • Obstetric measurements and gestational age • Fetal growth assessment • Prenatal diagnosis of congenital anomalies, with a separate chapter on 3D and 4D evaluation of fetal anomalies • Chapters devoted to the placenta, umbilical cord, and amniotic fluid, as well as to the fetal face and neck, neural axis, thorax, anterior abdominal wall, abdomen, urogenital system, and skeleton New to This Edition Ten new contributors joined the seventh edition to update and expand existing content, bringing with them a fresh perspective and an impressive knowledge base They also helped contribute the more than 1000 images new to this edition, including color Doppler, 3D, and contrast-enhanced images More than 30 new line drawings complement the new chapters found in the seventh edition Essentials of Patient Care for the Sonographer (Chapter 3) covers all aspects of patient care the sono­ grapher may encounter, including taking and understanding vital signs, handling patients on strict bed rest, patients with tubes and oxygen, patient transfer techniques, infection control, isolation techniques, emergency medical situations, assisting patients with special needs, and patient rights Ergonomics and Musculoskeletal Issues in Sonography (Chapter 4) outlines the importance of proper technique and positioning throughout the sonographic examination as a way to avoid long-term disability problems that may be acquired with repetitive scanning Understanding Other Imaging Modalities (Chapter 5) is a comparative overview of the multiple imaging modalities frequently encountered by the sonographer: computerized tomography, magnetic resonance, positron emission tomography (PET), nuclear medicine, and radiography Artifacts in Scanning (Chapter 6) is an outstanding review of all the artifacts commonly encountered by sonographers There are numerous examples of the various artifacts and detailed explanations of how these artifacts are produced and how to avoid them 3D and 4D Evaluation of Fetal Anomalies (Chapter 54) has a three-fold focus: (1) to introduce the sonographer to the technical concepts of 3D ultrasound; (2) to acquaint the sonographer with the 3D tools currently available; and (3) to provide clinical examples of the integration of 3D ultrasound into conventional sonographic examinations Although a chapter with this title appeared in the last edition, this chapter has been entirely rewritten and includes all new illustrations Student Resources Workbook.  Available for separate purchase, Workbook for Textbook of Diagnostic Sonography has also been completely updated and expanded This resource gives the learner ample opportunity to practice and apply the information presented in the textbook • Each workbook chapter covers all the material presented in the textbook • Each chapter includes exercises on image identification, anatomy identification, key term definitions, and sonographic technique • A set of 30 case studies using images from the textbook invites students to test their skills at identifying key anatomy and pathology and describing and interpreting sonographic findings • Students can also test their knowledge with the hundreds of multiple choice questions found in the four exams covering different content areas: General Sonography, Pediatric, Cardiovascular Anatomy, and Obstetrics and Gynecology Evolve.  On the Evolve site, students will find a printable list of the key terms and definitions for each chapter; a printable selected bibliography for each chapter, and Weblinks Instructor Resources Resources for instructors are also provided on the Evolve site to assist in the preparation of classroom lectures and activities • PowerPoint lectures for each chapter that include illustrations • Test bank of 1500 multiple-choice questions in Examview and Word • Electronic image collection that includes all the images from the textbook both in PowerPoint and in jpeg format Evolve Online Course Management.  Evolve is an interactive learning environment designed to work in coordination with Textbook of Diagnostic Sonography Instructors may use Evolve to include an Internet-based course component that reinforces and expands upon the concepts delivered in class Evolve may be used to: PREFACE • • • • • xiii Publish the class syllabus, outlines, and lecture notes Set up virtual office hours and email communication Share important dates and information on the online class calendar Encourage student participation with chat rooms and discussion boards Post exams and manage grade books For more information, visit http://www.evolve.elsevier com/HagenAnsert/diagnostic/ or contact an Elsevier sales representative CHAPTER 21  The Breast A 573 B C D FIGURE 21-32  Benign lesions of the breast A, Cyst B, Complex C, Fibroadenoma D, Malignant solid mass with spiculation implying that the mass is pushing against adjacent breast tissue, as opposed to infiltrating it Malignant lesions, on the other hand, tend to grow right through the normal breast tissue As malignant masses enlarge, they may cause retraction of the nipple or dimpling of the skin as the spiculations pull on Cooper’s ligaments (Figure 21-33) Shape.  A rounded or oval shape is usually associated with benign lesions; sharp, angular margins are associated with malignancy Mild undulations in contour can be seen in benign masses such as fibroadenomas; however, microlobulations (very small 1- to 2-mm lobulations) are more often associated with malignancy Lobulations associated with benign fibroadenomas are usually large, rounded lobulations and not exceed three in number Microlobulations associated with malignancy are usually smaller, sharper, and more numerous Orientation.  The normal tissue planes of the breast are horizontally oriented Benign lesions tend to grow within the normal tissue planes, and their long axis lies parallel to the chest wall Malignant lesions are able to grow through the connective tissue and may have a vertical orientation when the breast is imaged from anterior to posterior If a mass measures longer in the anteroposterior dimension (height) than in the transverse or sagittal plane (width), it has a vertical orientation, is usually FIGURE 21-33  Malignant lesions interrupt the normal breast architecture as they spread throughout the tissue, as shown on this tomographic presentation described as “taller-than-wide,” and is suspicious for malignancy Internal Echo Pattern.  Lesions that appear isoechoic with the breast parenchyma or have echoes equivalent to or brighter than that of fat are most often benign A 574 CHAPTER 21  The Breast solid lesion that is hypoechoic relative to the normal breast parenchyma is more suspicious for malignancy Malignant lesions tend to be highly hypoechoic relative to fat and usually have weak internal echoes They are often associated with dense posterior shadowing, making the lesion difficult to penetrate Microcalcifications within a solid mass are associated with a breast malignancy Ultrasound is less sensitive than mammography in the detection of microcalcifications due to the heterogeneous appearance of normal breast tissue Microcalcifications seen with ultrasound are typically very small echogenic foci that not create shadows because of their small size Although calcifications are not visualized frequently by sonography, their detection in a hypoechoic mass is suspicious for malignancy Attenuation Effects.  Enhancement behind a lesion is normally caused by a weakly attenuating structure; it usually indicates that the lesion is made up of fluid and is a characteristic associated with benign lesions Most solid lesions, with the exception of a fibroadenoma, will not enhance Shadowing behind a solid breast mass is another suspicious sonographic sign for malignancy because malignant tumors tend to be highly attenuating Posterior shadowing should not be confused with edge or refraction shadowing, in which shadowing occurs at the curved edge of a smooth, benign mass Mobility.  Benign lesions normally demonstrate a limited degree of mobility or may roll away as they are palpated Because of the spiculations associated with malignancy, malignant lesions are normally very fixed or rigid in their position Compressibility.  If pressure applied by the transducer causes the lesion to compress or change shape, the lesion is probably benign and most likely represents a fat lobule Malignant lesions normally are very hard and noncompressible Vascularity.  Doppler interrogation of a breast lesion is an essential element of the study Although breast lesions are not associated with consistent resistance patterns on Doppler ultrasound, malignant masses often demonstrate increased vascularity within the lesion and often have a feeder vessel, which can be identified upon careful evaluation Vessels that penetrate a mass are highly suspect for malignancy and should be checked using color or power Doppler to ascertain the number and to look for intratumoral vessels PATHOLOGY The most common pathologic lesions of the female breast are, in order of decreasing frequency, fibrocystic disease, carcinoma, fibroadenoma, intraductal papilloma, and duct ectasia Benign lesions are the most common breast lesions, representing 70% of proved lesions in biopsies after they are removed Several parameters, including the patient’s age, physical characteristics of the mass, and previous medical history, must be considered when a dominant mass has been palpated Lesions common to younger women are fibrocystic disease and fibroadenomas Older or postmenopausal women are more likely to have intraductal papilloma, duct ectasia, and cancer Differential Diagnosis of Breast Masses Symptoms of breast masses include pain, a palpable mass, spontaneous or induced nipple discharge, skin dimpling, ulceration, and nipple retraction Benign processes are usually associated with pain, tumor, and nipple discharge Skin dimpling or ulceration and nipple retraction nearly always result from cancer Benign tumors are rubbery, mobile, and well defined (as seen in a fibroadenoma), whereas malignant tumors are often stone hard and irregular with a gritty feel Soft tumors usually represent a lipoma (fat tissue) Cystic masses are like a balloon of water, well delineated but not as mobile as fibroadenomas because they form part of the breast parenchyma, whereas a fibroadenoma has a capsule Benign Conditions Cysts.  Cysts are commonly seen in women 35 to 55 years of age Symptoms include history of changing with the menstrual cycle, pain (especially when the cyst is growing rapidly), recent lump, and tenderness Small cysts may not regress completely and may persist from one cycle to the next Fibrocystic Condition.  Fibrocystic changes produce histologic alterations in the terminal ducts and lobules of the breast in both epithelial and connective tissue Fibrocystic changes are usually accompanied by pain or tenderness in the breast and represent normal physiologic processes of breast tissue that fluctuate under the influence of normal female hormonal cycles These processes become magnified in some patients to the point of causing symptoms that are upsetting to the patient (mainly pain and tenderness or recurrent cysts) In some cases, fibrocystic condition (FCC) causes changes that are frankly worrisome for breast cancer In all age groups, the most common diagnosis at breast biopsy is FCC These biopsies are prompted by a growing or dominant clinically suspicious breast lump The terms fibrocystic condition and fibrocystic change (use of the term fibrocystic disease is discouraged) actually encompass many different processes under a single term An abundance of inaccuracy and confusion results from using the term fibrocystic condition In some cases, FCC may refer to the normal hormonal fluctuations in breast texture At the other end of the spectrum, a surgical biopsy may be undertaken because of a growing suspicious breast lump In a few cases, a biopsy reveals tissue changes that mean the patient is at increased risk for subsequent development of breast cancer Clinical signs and symptoms of FCC include the lumps and pain that the patient feels that fluctuate with every monthly cycle In most cases, both breasts are equally involved In some cases, FCC may affect just one area of one breast This can be frightening for the patient and is a frequent cause of referral for diagnostic breast imaging Imaging signs of FCC may be visible on the mammogram or breast ultrasound On mammogram, FCC may cause diffuse benign microcalcifications, adenosis, and multiple round masses Ultrasound of the breast shows the round masses as multiple cysts (Figure 21-34) Many separate tissue processes of FCC are recognized by the pathologist in reviewing breast tissue under a microscope, including apocrine metaplasia, fibrosis, epithelial ductal hyperplasia, and sclerosing adenosis In correlating the pathologic results of a breast biopsy with the indication for biopsy (i.e., palpable breast lump, suspicious mammographic or sonographic mass, or clustered microcalcifications), it is very important for the physician to document that the pathologic results are concordant with the targeted lesion If a breast biopsy was performed because of suspicious microcalcifications, for example, the pathology report should state that microcalcifications were seen If no microcalcifications were seen on pathology slides, then this is a discordant result, and further investigation will be required In an attempt to create a more clinically relevant classification of tissue processes under the enormous and confusing heading of fibrocystic condition, these processes have been separated into three categories: (1) nonproliferative lesions (no increased risk of subsequent development of breast cancer); (2) proliferative lesions without atypical cells (mildly elevated risk of subsequent breast cancer); and (3) proliferative lesions with atypical cellular changes (moderately increased risk of subsequent breast cancer) Any woman with an atypical proliferative breast lesion (especially lobular neoplasia) who also has a family history of a first-degree relative with breast cancer will have double the risk of subsequent breast cancer compared with the patient with an atypical proliferative lesion alone (Table 21-3) CHAPTER 21  The Breast Fibroadenoma.  The most common benign breast tumors are fibroadenomas, and they occur primarily in young women They may be found in one breast or in both breasts The growth of a fibroadenoma is stimulated by estrogen Under normal circumstances, hormonal influences on the breast (estrogen) result in the proliferation of epithelial cells in lactiferous ducts and in stromal tissue during the first half of the menstrual cycle During the second half of the cycle, this condition regresses, allowing breast tissue to return to its normal resting state In certain disturbances of this hormonal mechanism, regression fails to occur, resulting in the development of fibrous and epithelial nodules that become fibroadenomas, fibromas, or adenomas, depending on the predominant cell type They may also be related to pregnancy and lactation Clinically, a fibroadenoma is firm, rubbery, freely mobile, and clearly delineated from the surrounding breast tissue (Figure 21-35) It is round or ovoid and smooth or lobulated, and usually does not cause loss of contour of the breast unless it develops to a large size It rarely causes mastodynia, and it does not change size during the menstrual cycle Fibroadenomas tend to grow very slowly A sudden increase in size with acute pain may be the result of hemorrhage within the tumor Calcification may follow hemorrhage or infarction; thus the tumor may have calcifications and may mimic the appearance of a carcinoma on mammography Sonographically, fibroadenomas have benign characteristics with smooth, rounded margins and low-level homogeneous internal echoes and may demonstrate intermediate TABLE 21-3 Fibrocystic Condition: Common Breast Lesions—Risk of Subsequent Breast Cancer Classification Description Nonproliferative lesions: no increased risk Cyst Apocrine metaplasia Fibroadenoma Ductal ectasia Mild epithelial ductal hyperplasia Benign microcalcifications Moderate or florid epithelial ductal hyperplasia Sclerosing adenosis Radial scar (complex sclerosing lesion) Intraductal papilloma Atypical ductal hyperplasia Atypical lobular hyperplasia Lobular neoplasia (alternative term for lobular carcinoma in situ [LCIS]) Proliferative lesions without atypical features: mildly increased risk (1.5 to 2×) Proliferative lesions with atypical features: moderately increased risk (4 to 6×) FIGURE 21-34  Fibrocystic condition shows two sonolucent structures within the breast 575 Note: Patients with an atypical proliferative lesion and a first-degree relative with breast cancer are at even greater risk for subsequent breast cancer 576 CHAPTER 21  The Breast FIGURE 21-35  Fibroadenoma Smooth, ovoid, solid mass with a low-level internal echo pattern posterior enhancement Fibroadenomas are normally hypoechoic, but occasionally are hyperechoic to the fat within the breast Lipoma.  A pure lipoma consists entirely of fatty tissue Other forms of lipoma consist of fat with fibrous and glandular elements interspersed (fibroadenolipoma) A lipoma may grow to a large size before it is clinically detected It is usually found in middle-aged or menopausal women Clinically, on palpation, a large, soft, poorly demarcated mass is felt that cannot be clearly separated from the surrounding parenchyma No thinning or fixation of the overlying skin is noted Sonographically, it may be difficult or impossible to detect a lipoma in a fatty breast Lipomas typically have smooth walls, are hypoechoic, and appear similar to fat They often demonstrate posterior enhancement and are easily compressible Fat Necrosis.  Fat necrosis may be caused by trauma to the breast, surgery, radiation treatments, or plasma cell mastitis or may be related to an involutional process or other disease present in the breast, such as cancer It is more frequently found in older women Clinical palpation reveals a spherical nodule that is generally superficial under a layer of calcified necrosis A deep-lying focus of necrosis may cause scarring with skin retraction and thus may mimic carcinoma Sonographically, fat necrosis appears as an irregular, complex mass with low-level echoes; it may mimic a malignant lesion and may appear as fat, but it is separate and distinct from the rest of the breast parenchyma Acoustic shadowing may or may not be present Acute Mastitis.  Acute mastitis may result from infection, trauma, mechanical obstruction in the breast ducts, or other conditions It often occurs during lactation, beginning in the lactiferous ducts and spreading via the lymphatics or blood Acute mastitis causes an enlarged, reddened, tender breast, and is often confined to one area of the breast Diffuse mastitis results when infection is carried via the blood or breast lymphatics and thus affects the entire breast Patients are treated initially with antibiotics and are referred for breast imaging when acute inflammatory symptoms are sufficiently reduced to allow good quality mammography and breast ultrasound to rule out inflammatory breast cancer as a cause Chronic Mastitis.  An inflammation of the glandular tissue is considered to be chronic mastitis This is very difficult to differentiate by ultrasound; the echo pattern is mixed and diffuse with sound absorption The condition is usually found in elderly women Thickening of the connective tissue results in narrowing of the lumina of the milk ducts The cause is inspissated intraductal secretions, which are forced into the periductal connective tissue Clinically, the patient usually has a nipple discharge; frequently, the nipple has retracted over a period of years Palpation reveals some subareolar thickening, but no dominant mass Abscess.  Abscesses may be single or multiple Acute abscesses have a poorly defined border, whereas mature abscesses are well encapsulated with sharp borders A definite diagnosis cannot be made from a mammogram alone Aspiration is necessary Clinical findings include pain, swelling, and reddening of the overlying skin The patient may be febrile, and swollen painful axillary nodes may be present Sonographic findings may show a diffuse, mottled appearance of the breast, irregular margins, posterior enhancement, and low-level internal echoes (Figure 21-36) If associated with mastitis, skin thickening is almost always present, and edema leads to diffusely increased echogenicity of the breast tissue Color or power Doppler of the breast may be helpful to document hyperemia associated with increased vascularity, which may tip the scales toward abscess rather than hematoma Cystosarcoma Phyllodes.  Cystosarcoma phyllodes is a rare, predominantly benign breast neoplasm It accounts for less than 1% of all breast neoplasms, yet it is the most frequent sarcoma of the breast It is more commonly found in women in their 50s and usually is unilateral It may arise from a fibroadenoma Many patients may notice that a small breast mass that has been present for a long time suddenly begins to grow rapidly Although it is considered a benign lesion, 27% of these tumors are malignant, and 12% metastasize When the tumor is small, it is well delineated, firm, and mobile, much like a fibroadenoma As it enlarges, the surface may become irregular and lobulated Skin changes can develop from increasing pressure Edema may produce a skin change Increasing pressure causes trophic changes and eventual skin ulcerations Infection and abscess formation may be a secondary complication The tumor never adheres to adjacent soft tissue or underlying pectoral muscle; therefore, dimpling of the skin or fixation of the tumor is not observed Sonographic findings include a large, hypoechoic tumor with well-defined margins and decreased through-transmission Internal echoes may be fine or coarse with variable amounts of shadowing Intraductal Papilloma.  An intraductal papilloma is a small, benign tumor that grows within the acini of the breast It occurs most frequently in women 35 to 55 years of age The predominant symptom is spontaneous nipple discharge arising from a single duct When the discharge is copious, it is usually preceded by a sensation of fullness or pain in the areola or nipple area that is relieved as the fluid is expelled It has a “raspberry-like” configuration on the mammogram and in this way helps to promote correlation between the mammogram and the sonogram Papillomas are usually small, multiple, and multicentric They consist of simple proliferations of duct epithelium projecting outward into a dilated lumen from one or more focal points (Figure 21-37), each supported by a vascular stalk from which it receives the blood supply Trauma may rupture the stalk, filling the duct with blood or serum Papillomas may grow to a large size and thus become palpable lesions They are some- FIGURE 21-36  Lactating breast abscess shows a diffuse mottled appearance of the breast with irregular margins and posterior enhancement CHAPTER 21  The Breast 577 what linear, resembling the terminal duct, and are usually benign Malignant Conditions Malignancies generally develop over a long time It is not unusual for several years to pass from the first appearance of atypical hyperplasia to the final diagnosis of in situ cancer Malignant cells grow along a line of least resistance, such as in fatty tissue In fibrotic tissue, most cancer growth occurs along the borders Lymphatics and blood vessels are frequently used as pathways for new tumor development If the tumor is encapsulated, it continues to grow in one area, compressing and distorting the surrounding architecture When the carcinoma is contained and has not invaded the basal membrane structure, it is considered in situ Most cancer originates in the terminal ductal lobular units, whereas a smaller percentage originates in the glandular tissue The breast lobules are concentrated in the upper outer quadrant of the breast, and so it is not surprising that a majority of breast cancers (50%) are found there, followed by lesser incidence in the retroareolar area (17%), upper inner quadrant (15%), lower outer quadrant (10%), and lower inner quadrant (5%) Multifocal masses are least common and occur in approximately 3% of cases Cancer of the breast is of two types: sarcoma and carcinoma Sarcoma refers to breast tumors that arise from supportive or connective tissues Sarcomas tend to grow rapidly and invade fibrous tissue Carcinoma refers to breast tumors that arise from the epithelium, in the ductal and glandular tissue, and usually has tentacles Other malignant diseases affecting the breast result from systemic neoplasms, such as leukemia or lymphoma Breast carcinomas are generally categorized by two factors: where the cancer cells originate (ductal or lobular), and whether the cancer is prone to spreading B A C FIGURE 21-37  Complex cyst with debris and intracystic mass A, Ultrasound image of a complex cyst with irregular dependent debris (arrows) B, Another image of the same complex cyst showing an intracystic mass (arrowhead) and thickened septations (arrows) C, Postaspiration pneumocystogram (air in cyst cavity) showing the intracystic mass (arrow) and the septations (small arrows) Intracystic masses are usually benign papillomas, but sometimes may be papillary carcinomas 578 CHAPTER 21  The Breast (noninvasive or invasive) Most breast carcinomas begin within the ducts of the breast and are called ductal or intraductal carcinomas Breast cancers that form in the lobules are called lobular carcinomas Carcinomas that not normally spread outside of the duct or lobule are called noninvasive, noninfiltrating, or in situ cancer, whereas cancers that spread into nearby tissue are said to be invasive or infiltrating Ductal Carcinoma In Situ (DCIS).  DCIS is also known as intraductal carcinoma DCIS is characterized by cancer cells that are present inside the ducts but have not yet spread through the walls of the ducts into the fatty tissue of the breast (Figure 21-38) Because these are confined to the duct and have not spread, they usually have a 100% cure rate Calcifications and ductal enlargement with extension within the ducts are common (Figure 21-39) Invasive Ductal Carcinoma (IDC).  IDC accounts for nearly 80% of breast cancers Similar to DCIS, these cancers begin in the ducts, but in contrast to DCIS, they invade the fatty tissue of the breast and have the potential to metastasize via the bloodstream or the lymphatic system It is important to get a definitive diagnosis and begin treatment before cancer spreads to other organs Lobular Carcinoma In Situ (LCIS).  Lobular carcinoma in situ (LCIS) is not considered a “cancer” because it has a low malignant potential LCIS is often referred to as lobular neoplasia and is classified as a precancerous growth that begins in the lobule LCIS is confined to the gland and does not penetrate through the wall of the lobule LCIS does not usually form a distinct mass and therefore can be difficult to pick up with the use of only mammography and ultrasound screening Women with LCIS are at higher risk of developing invasive breast cancer later on Invasive Lobular Carcinoma (ILC).  ILC begins in the lobule, where it extends into the fatty tissue of the breast Similar to IDC, invasive lobular carcinoma has the potential to metastasize and spread to other parts of the body ILC is the second most common type of invasive tumor, accounting for 10% to 15% of all breast cancers ILC is often bilateral, multicentric, or multifocal (Figure 21-40) Breast cancers are considered multifocal when more than one tumor is identified and when they are located within the same quadrant or ductal system and are within 5 cm of each other Breast cancers are considered multicentric when they are located in different quadrants and are located at least 5 cm apart Multifocal lesions tend to be of the same cell type histologically, whereas multicentric lesions are more likely to be of two different cell types The more favorable cancers remain localized to the breast longer, and treated patients have a 75% survival rate after 10 years They represent only 10% to 12% of all breast cancers This group includes medullary, FIGURE 21-38  Intraductal masses A, Sonographic image shows a large intraductal mass in a patient with a unilateral single-duct discharge (arrowheads) B, Magnification view from a galactogram, in which contrast was injected retrograde into the duct orifice from which the discharge was expressed Note the large filling defect (arrows) C, Sonographic image from another patient showing a small intraductal mass (arrows) Most intraductal masses are benign papillomas It is generally difficult, however, to distinguish an intraductal papilloma from an early intraductal cancer A C B CHAPTER 21  The Breast 579 A B C FIGURE 21-39  Suspicious microcalcifications (ductal carcinoma in situ [DCIS]) and occult infiltrating ductal carcinoma A, Magnification mammogram image of pleomorphic (irregular shapes) suspicious microcalcifications identified on screening mammogram in this asymptomatic young woman No mass was visible on the mammogram B, Sonographic demonstration of echogenic microcalcification within a dilated duct (arrows) C, Image of the same breast showing an unsuspected sonographic mass with suspicious features (note that the mass is taller than wide, shows an irregular indistinct margin, and shows asymmetric posterior shadowing and heterogeneous echogenicity) Ultrasoundguided large-needle core biopsy proved infiltrating malignancy This altered the patient’s management, requiring a mastectomy and axillary node dissection for staging intracystic papillary, papillary, colloid, adenoid cystic, and tubular carcinomas Other malignant tumors that have a better than average prognosis after treatment include malignant cystosarcoma phyllodes and stromal sarcomas, because they rarely metastasize to regional nodes Definitive identification of a tumor type can be made only by histologic (tissue) examination Although many solid lesions have definite malignant characteristics, crossover of benign and malignant characteristics is often seen on ultrasound, and the nature of the lesion is indeterminate by sonographic evaluation alone It is not uncommon for malignant lesions to have a benign appearance on ultrasound, thus making it extremely important to consider the patient’s risk factors and clinical history when considering the differential diagnosis The following is a brief description of the more common malignancies affecting the breast Comedocarcinoma.  Intraductal solid carcinoma in which the lactiferous ducts are filled with a yellow pastelike material that looks like small plugs (comedones) when sectioned is called comedocarcinoma Histologically, the ducts are filled with plugs of an epithelial tumor that have a central necrosis, giving rise to the pastelike material Both invasive and noninvasive forms exist Noninvasive forms may lack any clinical or palpatory findings If a nipple discharge occurs, it is more frequently clear than bloody (unlike papillary carcinoma, in which bloody discharge is typical) The patient may complain of pain or the sensation of insects crawling on the breast With early invasion, minimal thickening of the surrounding breast tissue may be palpated In the advanced stage, clinical signs include nipple retraction, dominant mass, and fixation Microcalcifications are commonly seen on mammography and may be picked up sonographically Intraductal carcinomas have malignant characteristics, including irregular margins, a diffuse internal echo pattern, and attenuation with shadowing Juvenile Breast Cancer.  Juvenile breast cancer is simi­ lar to ductal carcinoma in situ and invasive ductal CHAPTER 21  The Breast 580 A B D C FIGURE 21-40  Infiltrating lobular carcinoma A, Craniocaudal view of both breasts shows portion of nodular density (arrow) in posterior central right breast B, Spot compression magnification view shows wispy area (arrow) of parenchymal density in the inframammary fold corresponding to the nodule on the craniocaudal view C, Sonogram of area of mammographic abnormality shows hypoechoic, ill-defined area of architectural distortion (AD) with infiltration (arrow) into the adjacent fibroglandular parenchyma (F); ultrasound-guided biopsy confirmed the diagnosis of infiltrating lobular carcinoma D, In another patient with vague thickening on self-examination, a mammogram showed dense glandular tissue but no focal mass Ultrasound demonstrates an extensive hypoechoic angular mass (M) occupying nearly two thirds of the breast Fibroglandular tissue (F) carcinoma as found in adults Generally, it occurs in young females, between and 15 years of age, and has a good prognosis when treated early Papillary Carcinoma.  Papillary carcinoma is a tumor that initially arises as an intraductal mass It may also take the form of an intracystic tumor, which is rare The early stage of papillary carcinoma is noninvasive The tumor occasionally arises from a benign ductal papilloma It is associated with little fibrotic reaction Both intraductal and intracystic forms exist, and these represent 1% to 2% of all breast carcinomas The earliest clinical sign of intraductal papillary carcinoma is bloody nipple discharge Occasionally, a mass can be palpated as a small, firm, well-circumscribed area and may be mistaken for a fibroadenoma (Figure 21-41) Nodules of blue or red discoloration may be found under the skin with central ulceration A diffusely nodular appearance overlying the skin is a special variant of multiple intraductal papillary carcinoma Intracystic papillary carcinoma is clinically indistinguishable in its early stages from a cyst or fibroadenoma When the tumor has invaded through the cyst wall, it is palpable as a poorly circumscribed mass Papillary carcinoma typically has a more favorable prognosis than other types of carcinoma CHAPTER 21  The Breast 581 A B FIGURE 21-41  Papillary carcinoma A, Mediolateral oblique view of the left breast shows well-circumscribed mass containing area of increased density Slight marginal irregularity is seen (arrows) B, Circumscribed complex mass with anterior protuberance (curved arrow) Central area of echogenicity is surrounded circumferentially by what most likely represents the cystic component (C) of this in situ papillary carcinoma with stromal invasion Paget’s Disease.  Paget’s disease arises in the retroareolar ducts and grows in the direction of the nipple, spreading into the intraepidermal region of the nipple and areola, and has a rashlike appearance that may be confused with a melanoma Any ulceration, enlargement, or deformity of the nipple and areola should suggest Paget’s disease This is a relatively rare tumor, accounting for 2.5% of all breast cancers It typically occurs in women over 50 years of age Differential diagnosis includes benign inflammatory eczematous condition of the nipple, because palpatory findings frequently are not present The primary ductal cancer may be quite deep or embedded in fibrotic tissue Sonographically, Paget’s disease will present as a retroareolar mass with irregular margins, heterogeneous internal echoes, and attenuation with posterior shadowing Scirrhous Carcinoma.  Scirrhous carcinoma is a type of intraductal tumor with extensive fibrous tissue proliferation (very dense fibrosis) Focal calcification may also be present Histologically, the cells are found in narrow files or strands, clusters, or columns and may form lumina with varying frequency Scirrhous carcinoma is the most common form of breast cancer and often has no specific histologic findings or patterns; therefore it is often classified as ductal carcinoma that is not otherwise specified (NOS) The classic clinical signs include a very firm nodular, frequently nonmovable mass, often with fixation and flattening of overlying skin and nipple retraction The retraction is a result of an infiltrative shortening of Cooper’s ligaments caused by productive fibrosis (see Figure 21-22) Fixation and retraction of the nipple may be the result of a subareolar carcinoma, but may also be caused by benign fibrosis of the breast It is important to note that some patients normally have inverted nipples The size of the cancer may vary from a few millimeters to involvement of nearly the entire breast The deep-lying scirrhous carcinoma may grow into and become fixed to the thoracic wall A bloody discharge is rare with this tumor Medullary Carcinoma.  Medullary carcinoma is a densely cellular tumor that contains large, round, or oval tumor cells It usually is a well-circumscribed mass, with the center frequently necrotic, hemorrhagic, and cystic (Figure 21-42) Medullary carcinomas are relatively rare, accounting for less than 5% of breast cancers The age of occurrence is slightly lower than for the average breast cancer, with a majority of cases occurring in women younger than 50 Medullary carcinomas are usually well circumscribed, often large, and resemble fibroadenoma with a fairly benign appearance Discoloration of the overlying skin is often seen as a clinical finding, and bilateral occurrence is more frequent with medullary carcinoma than with other cancers Colloid Carcinoma.  Colloid carcinoma (mucinous) is a relatively rare type of ductal carcinoma that accounts for approximately 3% of breast carcinomas The cells of the tumor produce secretions that fill lactiferous ducts or stromal tissues in which the tumor cells are invading Clinically, the tumor presents in older women as a slowgrowing, smooth, and not particularly firm mass upon palpation The sonographic appearance is often similar to a fibroadenoma with smooth margins and posterior enhancement The echotexture has been described as having a “salt and pepper” appearance (Figure 21-43) 582 CHAPTER 21  The Breast Tubular Carcinoma.  Tubular carcinoma represents an extremely well-differentiated form of infiltrating (invasive) ductal carcinoma usually less than 2 cm in dimension Tubular carcinoma occurs in women with an average age of 50 and has a favorable prognosis with a low rate of recurrence or metastasis Death is rare Tubular carcinoma typically has poorly circumscribed margins and a hard consistency (Figure 21-44) Ultrasound-Guided Interventional Procedures FIGURE 21-42  Medullary carcinoma Sonogram depicts lobulated mass (arrows) with ill-defined margins, low-level internal echoes, and a small amount of posterior acoustic enlargement Ultrasound is an important guide for many diagnostic and interventional procedures in the breast These include cyst aspiration, fine-needle aspiration cytology (FNAC), abscess or seroma drainage, large-core needle biopsy, vacuum-assisted needle biopsy, ultrasoundguided preoperative needle wire localization for surgical excision, and injection of a radiopharmaceutical agent for sentinel node identification and biopsy (Box 21-12) Sterile coupling gel is available commercially, as are sterile plastic transducer sleeves It is possible and more cost effective to use isopropyl alcohol as a coupling agent during procedures When ultrasound is used to guide any diagnostic or interventional procedure in the breast, the high-frequency, narrow-beam linear array transducer is a valuable tool Even narrow-gauge needles (22 or 25 gauge) can be seen and accurately guided into cysts or masses The key to B A FIGURE 21-43  Mucinous (colloid) carcinoma A, Spot compression mammographic view of palpable (denoted by radiopaque marker) cir- cumscribed mass A satellite nodule suggestive of diverticulum is seen laterally (curved arrow) B, Sonography of a portion of the mass shows that the sonographic margins are well defined and the diverticulum-like satellite (curved arrow) is easily seen This homogeneous mass shows posterior acoustic enhancement CHAPTER 21  The Breast A 583 B FIGURE 21-44  Tubular carcinoma A, Magnified mammographic view shows mass with central radiolucent areas and very long radiating spiculation, suggesting radial scar B, Sonogram depicts 0.7-cm, solid, hypoechoic mass with irregular, poorly defined margins (arrows) and posterior acoustic attenuation—common features of carcinoma BOX 21-12 Ultrasound-Guided Interventional Procedures Cyst aspiration Fine-needle aspiration cytology (FNAC) Drainage procedures Preoperative needle (wire) localization Large-core needle biopsy Vacuum-assisted needle biopsy Sentinel node biopsy visualizing the needle is to keep it oriented as nearly parallel to the transducer face as possible Accuracy in placing the needle tip within the target lesion is also aided when the lesion is kept in the field of vision along with the needle (Figure 21-45) This protects the patient, because the main hazard for the patient is inadvertent piercing of the chest wall Puncture of the lung resulting in a pneumothorax can occur in some cases with asthenic patients (especially those with emphysema, in which case the lung may protrude between ribs) If care is taken to maintain the needle parallel to the transducer face, the needle tip will remain parallel to the chest wall, and this will help prevent potential complications Another important consideration in planning needle procedures in the breast is the approach When dealing with any breast lesion that has the potential for malignancy, selection of the needle approach can have consequences in future therapeutic and reconstructive surgical procedures Although the shortest approach from skin to target lesion has been advocated in the past for preoperative needle wire localizations and is often the favored route for ultrasound-guided core biopsy, a more horizontal approach will often facilitate a better cosmetic outcome for the patient if a mastectomy is necessary Preprocedure consultation with the referring surgeon concerning the approach for needle wire localizations and core biopsies will ensure the best final outcome for the patient Cyst Aspiration.  Cyst aspiration is a common interventional technique used in the breast The cystic fluid is usually “straw-colored” when it is withdrawn, unless it is tinged with blood The two main indications are a symptomatic cyst (one large enough to create a palpable lump or to cause a patient pain) and a hypoechoic lesion on ultrasound that does not meet criteria for a simple cyst (Figure 21-46) In the latter situation, aspiration determines whether the lesion is simply a complex cyst or a solid mass This distinction is important for patient management Occasionally, cyst aspiration will be undertaken because cysts are so large or so numerous that visualization of breast tissue by mammogram is significantly compromised Fine-Needle Aspiration Cytology (FNAC).  The FNAC procedure uses a fine needle (usually 25 gauge) and an aspiration technique intended to harvest individual cells for diagnosis The technique is used in the United States and many other countries It is fast, easy for the patient, and generally very cost effective The single greatest problem in FNAC is obtaining an adequate specimen Another limitation in FNAC is the requirement for a 584 CHAPTER 21  The Breast Hand-held linear array transducer Needle tip Needle Target lesion FIGURE 21-45  Placement of the needle tip is facilitated by keeping it in the field of vision and as parallel as possible to the transducer surface A B C FIGURE 21-46  Complex cyst A, Mammogram shows a smooth, benign appearing dominant mass B, Ultrasound shows a lobular, smooth, hypoechoic lesion with weak posterior acoustic enhancement Cyst aspiration attempt under ultrasound guidance was done to assess this lesion as cystic or solid Benign cyst fluid was obtained, and a pneumocystogram (air injected through the aspiration needle into the cyst cavity with a postaspiration mammogram) was performed C, Postaspiration view of a normal pneumocystogram (arrowheads) after successful aspiration of a complex cyst Pneumocystography can be used to exclude the possibility of an intracystic mass and may prevent or retard cyst recurrence specially trained and experienced pathologist (cytopathologist)—not available in many centers This technique has not been as popular in the United States in part because of the somewhat greater inaccuracy of FNAC diagnosis (especially in fibrous malignant lesions and in proliferative benign lesions), and because of the greater availability of the more accurate (although more invasive) large-core needle biopsy Drainage Procedures.  When clinically indicated, most cases of breast abscess, seroma, or hematoma will be easily palpated and drained in a simple office procedure by a breast surgeon or other physician In some cases, the physician or surgeon may request ultrasound guidance These lesions differ from simple cysts in that they typically require a larger needle (at least 18 gauge); have thicker, more fibrous capsules; have thicker fluid, often with abundant cellular debris; and frequently have numerous fibrous synechiae within the lesion that can interfere with complete evacuation of contents The goal in therapy of a breast abscess is complete eradication of the abscess, usually accomplished through a combina- tion of drainage and antibiotic therapy Seromas and hematomas are fluid accumulations within the breast that are not infected These lesions have similar imaging characteristics (smooth mammographic mass, complex cyst on ultrasound) They differ in the quantity of blood and blood by-products within the fluid They usually are encountered during healing from surgical procedures and are not infrequently seen after lumpectomy or following a large-core needle biopsy In some cases, blunt trauma may lead to a hematoma, and occasionally, foreign body reaction or implant rupture may cause a seroma Preoperative Needle Wire Localization.  Ultrasound offers a quick method for placement of a percutaneous needle wire assembly for preoperative localization of a nonpalpable breast lesion for surgical excision (Figure 21-47) Ultrasound guidance offers a significant advantage in complicated cases, such as localization of a lesion adjacent to a breast implant (Figure 21-48), a lesion close to the chest wall, or a lesion in other areas not easily approached under mammographic guidance CHAPTER 21  The Breast A 585 B C FIGURE 21-47  Preoperative needle wire localization of spiculated cancerous mass A, Ultrasound image shows a sonographic mass with suspicious features B, Ultrasound image shows the echogenic wire through the center of the mass C, Mammogram taken after wire placement shows the hook wire through the center of the cancerous mass This wire placement aids the surgeon in identifying and removing tissue around the target mass Large-Core Needle Biopsy.  Ultrasound offers a fast and easy method for guiding large-core needle biopsy of solid masses Patient comfort is enhanced, procedure time is often shorter, and ultrasound guidance is more cost effective in general than prone stereotactic procedures It should be noted, however, that stereotactic guidance is still the preferred method for evaluation of clustered pleomorphic microcalcifications, which are difficult to see by ultrasound An exception to this rule is illustrated in Figure 21-49, in which ultrasound scanning of a patient with multiple suspicious microcalcifications noted on a screening mammogram revealed an unsuspected solid mass Ultrasound-guided core biopsy of the solid mass revealed infiltrating malignancy, which altered the patient’s management Vacuum-Assisted Needle Biopsy.  A relatively new breast biopsy technique is vacuum-assisted breast biopsy This type of biopsy is a percutaneous procedure that relies on stereotactic mammography or ultrasound imaging for guidance Stereotactic mammography is performed using computers to pinpoint the exact location of a breast mass taken from two different angles The computer coordinates help the physician guide the needle to a position posterior to the mass Ultrasound may also be used to guide the needle and allows the physician to observe the biopsy procedure in “real-time.” Vacuumassisted biopsy is a minimally invasive procedure that allows the removal of multiple larger tissue samples with a single insertion of the needle A special biopsy probe and needle are used The needle used in a vacuumassisted biopsy is generally of a larger gauge than needles used for core biopsies and has a special cutting blade at its tip to make the needle easier to insert The opening of the needle (aperture) is located along the side of the needle on the distal end Under ultrasound guidance, the needle is inserted immediately posterior to the tumor Once sampling is initiated, a vacuum pulls the tumor into the opening on the needle, and a rotating cutting blade slices the tissue The tissue sample is sent to a special chamber in the biopsy probe, where it can be retrieved without removal of the needle This technique allows multiple tissue samples to be taken with minor rotations of the needle It is also possible to completely remove smaller masses by taking multiple samples Sentinel Node Biopsy.  Standard surgical therapy for breast cancer has, for many years, involved a full level I 586 A CHAPTER 21  The Breast B FIGURE 21-48  Preoperative needle wire C D localization of sonographic mass adjacent to saline breast implant A, Ultrasound image shows a small, solid mass (arrows) near the anterior margin of the patient’s intramammary saline implant B, Under ultrasound guidance, the needle wire assembly can be guided carefully through the mass, avoiding inadvertent piercing of the implant C and D, Mammogram and ultrasound performed after wire placement show the position of the wire adjacent to the implant The wire (arrowheads) did not pierce the implant The arrow identifies the approximate position of the target mass (not visible on mammogram) FIGURE 21-49  Ultrasonic guidance for a needle biopsy may aid the clinician in accurate needle placement when the suspected mass is large enough to be imaged with sonography The needle is shown as the linear bright straight line as it approaches the solid mass Threedimensional imaging assures the clinician that the needle is correctly placed within the lesion for biopsy and at least a partial level II axillary lymph node dissection This results in a small but significant rate of morbidity from lymphedema or nerve damage, or, in severe cases, loss of arm and shoulder function An important step forward in surgical therapy for breast cancer involves sentinel node biopsy (SNB) In this procedure, the superficial subcutaneous tissues around the tumor bed and/or the areola are injected with methylene blue dye and/or radioactive-labeled solution (usually technetium-labeled filtered sulfur colloid) Both of these substances are taken up by the lymphatics and transported to the first, or “sentinel,” lymph node along the axillary node chain This lymph node is then identified in surgery and is carefully analyzed for evidence of metastasis This is generally followed by a limited axillary node dissection Early experience with this procedure shows an excellent accuracy rate for detecting lymph node metastases, which results in a reduced rate of morbidity and a faster recovery for the patient (Figure 21-50) CHAPTER 21  The Breast 587 FIGURE 21-50  Injection of radiopharmaceutic agent around tumor for sentinel lymph node identification Ultrasound image showing echogenic fluid (arrow) being injected into the superficial tissue around a mass (arrowhead) The needle is visible (small arrow) Injection of radioactive tracer in a saline solution can be done around the tumor, in the subcutaneous tissue over the tumor, and/or in the periareolar tissue Over several hours, the radioactive tracer will move through the breast lymphatic system and into the first or “sentinel” lymph node, usually the lowest node in the level I axillary lymph node chain ... illustrations 32 51 Riverport Lane St Louis, Missouri 63043 TEXTBOOK OF DIAGNOSTIC SONOGRAPHY   ISBN: 978-0-323-073 01- 1 Copyright © 2 012 by Mosby, Inc., an affiliate of Elsevier Inc No part of this publication... on the code of ethics for the profession of diagnostic medical ultrasound; the nondiagnostic use of ultrasound; the scope of practice for the diagnostic ultrasound professional; and diagnostic. .. Velocity 0.00 01 1.38 1. 50 1. 61 1.62 1. 65 1. 70 7.80 3 31 1450 14 30 15 70 15 60 15 50 15 80 4080 Frequency.  Sound is characterized according to its frequency (Figure 1- 6) Frequency may be explained by