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Sonography of The Breast
Holdorf PhD, MPA, RDMS (Ob/Gyn, Ab, BR), RVT, LRT(AS), CCP
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Part one: Introduction/Overview
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Anatomy and Physiology
Breast Development
Breast Screening
Sonographic Evaluation
Benign Conditions
Malignant Conditions
Interventional Breast Procedures
 Part Two
 Module One
 Module Two
 Module Three
 Module Four
 Module Five
 Part Three
 Module Six
 Module Seven
 Module Eight
 Module Nine
 Module Ten
 Module Eleven
Introduction
Instrumentation
Anatomy and Physiology
Mammography
Sonography
Benign Disease
Malignant Disease
Other Breast Imaging and Testing
Breast Augmentation
Invasive Procedures
Staging and Treatment
 Practice Mock Final Exam
 Final Exam
 Homework Assignments due every week as assigned
which includes various SDMS Breast Webinars.
Anatomy and Physiology of the Breast
Breast Development
Breast Screening
Sonographic Evaluation
Benign Conditions
Malignant Conditions
Interventional Breast Procedures
BI-RADS Breast Imaging-Reporting and Data System (ACR)
 Assessment Codes:
 0 Incomplete
 1 Negative
 2 Benign findings (100%) CYST
 3 Probably benign (< 2% chances of cancer)
 4 Suspicious (3-94% chance of cancer) Sub cats
 5 Highly suggestive of malignancy (> 95%)
 6 Known biopsy proven cancer
Mammography Reports
 BI-RADS Recommendations
0 Needs additional imaging evaluation (incomplete study)
1 Annual screening (> 40 yearly)
2 Annual screening
3 Short-term follow-up (usually 6 months)
4 Tissue sampling is required
5 Definitive treatment required (biopsy or surgery)
6 Definitive treatment required
Sub cats for BI-RAD 4
 4A: low suspicion for malignancy
 4B: intermediate suspicion of malignancy
 4C: moderate concern, but not classic for malignancy
Breast Composition Categories
 1: Almost entirely fatty
 2: Scattered fibro-glandular densities
 3: Heterogeneously dense
 4: Extremely dense
The Breast is a modified sweat gland located in the
superficial fascia of the anterior chest wall.
The major portion of the breast tissue is situated between the
second or third rib superiorly…
the sixth or seventh costal cartilage inferiorly…
the anterior axillary line laterally…
and the sternal border medially.
 In many women, the breast extends deep toward the
lateral upper margin of the chest and into the axilla.
 This extension (the axillary tail of the breast) is
referred to as the tail of Spence.
 Actually, the breast is TEAR SHAPED.
The tail of Spence
The surface of the breast is dominated by the nipple and the
surrounding areola.
A few women may have ectopic breast tissue or accessory
(supernumerary) nipples.
Ectopic breast tissue and accessory nipples are usually located along the
mammary milk line, which extends superiorly from the axilla downward
and medially in the oblique line to the symphysis pubis of the pelvis.
Sonographically, the breast is divided into three layers:
The subcutaneous layer-8
The mammary (glandular) layer-9
the retro-mammary layer-10
The subcutaneous and retromammary layers are usually quite thin
and consists of fat surrounded by connective tissue speta.
The fatty tissue appears hypoechoic while the ducts, glands, and
supporting ligaments appear echogenic.
The mammary/glandular layer includes the functional portion of
the breast and the surrounding supportive (stromal) tissue.
The functional portion of the breast is made up of 15 to 20 lobes,
which contain the milk-producing glands, and the ductal system,
which carries the milk to the nipple.
The lobes emanate from the nipple in a pattern resembling the
spokes of a wheel.
The upper-outer quadrant of the breast contains the highest
concentration of lobes.
This concentration of lobes in the upper-outer quadrant of the
breast is the reason a majority of tumors are found there.
Each lobule contains acini (milk-producing glands) which are
clustered on the terminal ends of the ducts like grapes on a vine.
The terminal ends of the duct and the acini form small lobular
units referred to as terminal ductal lobular units (TDLU).
The space between the lobes is filled with connective and fatty
tissue known as stroma.
 These stromal elements are located both between and
within the lobes and consists of dense connective
tissue, loose connective tissue, and fat.
Connective tissue septa are collectively called Cooper’s ligaments.
Muscles sonographically appear as a hypoechoic interface
between the retromammary layer of the breast and the ribs.
Subcutaneous fat generally appears hypoechoic, whereas
Cooper’s ligaments and other connective tissue appear echogenic
and are dispersed in a linear pattern.
The mammary/glandular layer lies between the subcutaneous
fatty layer anteriorly and the retromammary layer posteriorly.
The ribs sonographically appear as hyperechoic rounded
structures with dense posterior shadowing.
The size and shape of the breast varies remarkably from woman to
woman.
The size and shape of the breast varies over time because of the
changes that occur during the menstrual cycle, with pregnancy/breast
feeding, and during menopause.
Breast Pain Cycle
Generally, in a young woman, fibrous tissue elements
predominate and the resulting appearance on mammography and
ultrasound is a dense, echogenic pattern of tissue.
In a pregnant or lactating woman, the glandular portions of the
breast poliferate remarkably. (non-lactating vs. engorged breast)
As a woman ages, the glandular breast tissue undergoes cell death
and is remodeled by the infiltration of fatty tissue.
The main arterial supply to the breast comes from the internal
mammary and the lateral thoracic arteries.
Venous drainage is mainly provided by superficial veins that can
be seen sonographically just under the skin.
Lymphatic drainage from all parts of the breast generally flows to the
axillary lymph nodes. Only about 3% of lymph is eliminated by the
internal chain, whereas 97% of lymph is removed by the axillary chain.
The male breast
In males, the nipple and areola remain relatively
small
 The male breast normally retains some
ductal elements beneath the nipple, but
does not develop the milk-producing
lobular and acinar tissue.
Male breast hypertrophy is called benign Gynecomastia.
Although breast cancer is uncommon in males, it does occur.
Approximately 1300 new cases are diagnosed each year within
the United States.
Physiology of the Breast
 The primary function of the breast is to transport
fluid.
 The breast includes the fat, ligaments, glandular
tissue, and ductal system that work together to provide
a fluid transport, and only one entity in this group
produces milk.
 The ductal system is critical in the transport of fluids
within the breast and it is also a source for ductal
pathologic conditions.
 Ducts consist of epithellum cells, which line the
interior of the ducts, and a myoepithelium set of cells,
which controls the contractibility of the ducts.
 Milk is produced within the acini and is carried to the
nipple by the ducts.
Hormones
 The female breast is affected by hormonal levels
during each menstrual cycle and is further affected by
both pregnancy and lactation.
Breast development begins before menarche and continues until
the female is approximately 16 years old.
During this time, the ductal system proliferates under the
influence of estrogen.
 During pregnancy, acinar development is accelerated
to enable milk production by estrogen, progesterone,
and prolactine.
 Prolactine is a hormone produced by the pituitary
gland, which stimulates the acini to produce and
excrete milk.
The physical stimulation of sucking by the baby initiates the
release of oxytocin which further incites prolactin secretion,
stimulating additional milk production. (Oxytocin delivers milk)