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Fig. 1.8 1–2 Fine needle
aspiration biopsy of the
breast
191 Diagnosis of Breast Cancer: Modern Aspects
allow differentiation of the lesion (Semiglazov
et al. 2001 ) . This fact is often the result of poor
guidance, small number or total absence of cellular substrate in obtained material, or complications
during the procedure.
Vacuum-assisted breast biopsy with stereotac-
tic mammography or ultrasound guidance is an
ergonomic and highly effective method of obtaining cellular material for veri fi cation. It permits to
obtain multiple samples of tissue via a single
needle. The procedure can be carried out not only
with diagnostic but also with the treating purpose
(Fig. 1.9 ).
According to Ponedelnikov et al. ( 2011 ), the
diagnostic accuracy of FNAB is 32 %, core needle biopsy is 57 %, and vacuum-assisted biopsy
is 98 %.
Ultrasound (US) is now one of the most wide-
spread and affordable imaging methods for diagnosis of breast pathology, early and differential
diagnosis of breast masses, and guidance of minimally invasive modalities.
20
Fig. 1.9 1–2 Vacuum-
assisted biopsy of a breast
lesion
1 Diagnosis of Breast Cancer: Modern Aspects
US exhibits the following advantages in diag-
nosis of breast pathology:
High resolution of modern US equipment and •
high diagnostic value.
It is relatively simple to perform, fast, and •
cost-effective.
Noninvasive and painlessness. •
Can be done without any preparation of a •
patient.
Has no contraindications. •
Harmless and safe for the patient, hence pos-•
sible to be used for children, pregnant women
and feeding mothers, and patients with serious
accompanying pathology, and perform multi-
ple repeated examinations.
Permits differential diagnosis based on com-•
plex analysis of grayscale, Doppler modes, 3D
reconstruction, and other options.
Supports objective follow-up by means of •
digital archiving.
Permits computer processing, archiving of US •
data in an objective form suitable for delayed
analysis and digital transfer with virtual consul-
tations via telemedicine systems and Internet.
Supplies precise guidance for minimally inva-•
sive manipulations.
211 Diagnosis of Breast Cancer: Modern Aspects
Table 1.1 Sensitivity and speci fi city of US in diagnosis
of breast carcinoma
Sensitivity
Author Year
Lee et al. 1995 94.5 83.3
Sinyukova et al. 2007 83.6 86.9
Zikiryahodzhaev
et al.
Trufanov et al. 2009 92.3 84.1
Zubarev 2009 78.9 95.2
Rozhkova et al. 2010 73.3 92.8
Sencha et al. 2010a 93.3 73.7
Yemelyanov et al. 2011 76
Rozhkova et al. 2011 78.6 94.5
2008 85 90
(%)
Speci fi city
(%)
High ef fi cacy of US in diagnosis of breast
carcinoma results from high sensitivity and
speci fi city (Table 1.1 ).
The sensitivity of US in diagnosis of different
variants of breast carcinoma depends on the histological type of a neoplasm and ranges from
56.2 to 100 %. If added to mammography, US
increases the sensitivity in detection of early
impalpable cancer. US demands certain skills,
detailed knowledge of the anatomy and physiological changes of the breast, correlations of
fi ndings with clinical signs, results of mammography, and other diagnostic methods.
US is thought to be inappropriate for screening of breast cancer. This opinion is based on several disadvantages, as follows:
Impossibility to image the breast as a whole •
Low diagnostic value in cases of fatty •
involution
Subjective interpretation •
Impossibility of detection of noninvasive intra-•
ductal neoplasms in the form of calci fi cations
without tumoral mass
According to Gordon and Goldenberg ( 1995 ),
the probability of sonographic detection of
impalpable malignant breast tumor, which was
missed at mammography, accounts for only
1.8 %. Now the situation has critically changed
due to signi fi cant development of US equipment.
There appeared the possibility to detect minimal pathological changes of breast parenchyma
(lesions from 1 to 2 mm) and register pathognomonic signs for differentiation between benign
and malignant processes. Modern US scanners
in the majority of cases permit con fi rmation of
mammographic conclusion of a breast carcinoma
and allow to diagnose X-ray-negative tumors.
According to Otto ( 1993 ) the rate of detection
of mammography-negative breast malignancies
reaches 62 %.
US is a primary method of examination in the
following cases:
Pregnant women and nursing mothers •
Dense breast background in young women •
Differential diagnosis between solid and cavi-•
tary lesions
Early assessment of the breast after trauma or •
acute in fl ammation
Detection of regional and peripheral lymph •
nodes
Guidance of biopsies •
Assessment the condition of silicone implants •
The role of US is great in de fi nition of breast
masses in the areas that are technically dif fi cult
to examine with other imaging methods (e.g., on
the margin of medial quadrants near the breast
bone, in aberrant mammary lobes). US is unique
for the analysis of the whole breast vascularity
and vascular pattern of its lesions. Additionally,
US precisely characterizes abnormal lymph
nodes.
Technique of Breast Ultrasound
2
Breast US does not demand special preparation
of the patient. The optimum period for examination is the fi rst phase of menstrual cycle in fertile
women.
Indications for breast US are the following:
Complaints and symptoms, which are often •
associated with breast pathology, such as the
change in shape, pulling in of the nipple, discomfort or pain, and hyperemia
Pathological discharge from nipples •
Palpable lesions within the breast, in axillary, •
subclavian, or parasternal areas
Breast pathology revealed by other diagnostic •
methods
Chronic diseases of female reproductive •
sys tem
Follow-up the patients treated for breast •
diseases
Postoperative period •
Annual preventive examination •
Breast US is performed with linear probes
with the frequency of 5–12 MHz, more often
7.5–10 MHz. Retromammary space is better
examined with a 5.0 MHz probe and the nipple
and areola with 10 MHz or higher frequency
probe.
The patient is positioned supine with the hands
under the head (Fig. 2.1 ).
In the case of large breast, it is reasonable to
carry out the examination with the patient on her
back, on the right and left side, and in sitting
position with her hands under the head. The probe
is positioned perpendicularly to the breast skin.
The compression should be limited.
While describing the location of pathological
process, the breast is conventionally divided into
four quadrants: upper(superior)-outer(lateral),
upper(superior)-inner(medial), lower(inferior)inner(medial), and lower(inferior)-outer(lateral).
Subareolar area (central portion) and the nipple
are mentioned separately. The terminology of
“clock positions” is appropriate as additional
subsite descriptor to indicate the exact location
of abnormality (Fig. 2.2 ).
The examination, as a rule, begins with the
intact breast or at any side in cases of no complaints. The direction of scanning does not
matter. Breast US more often begins with the
upper-outer quadrant of the right breast and follows clockwise with the probe movements in
radial direction from the periphery to the nipple
area along the course of lactiferous ducts. The
examination of the left breast often starts with
the upper-inner quadrant proceeding clockwise.
For more detailed examination, the scans are
repeated in a clockwise circular direction from
periphery to nipple area. Special attention is paid
to subareolar and nipple areas, since the acoustic
shadow from the nipple can hide various pathological processes.
The following instances should be assessed
during breast US:
A. The breast as a whole
Location, symmetry •
Echodensity •
Echostructure, the ratio of fatty and •
glandular tissue
Condition of lactiferous ducts •
A.N. Sencha et al., Breast Ultrasound,
DOI 10.1007/978-3-642-36502-7_2, © Springer-Verlag Berlin Heidelberg 2013
23
24
Fig. 2.1 Breast US.
( a ) Patients position.
( b ) Position of US probe
2 Technique of Breast Ultrasound
a
b
Fig. 2.2 O’clock positions
and quadrants of breasts
252 Technique of Breast Ultrasound
Nipple area and areola •
Blood vessels of the parenchyma (symme-•
try and intensity of vascularization)
B. Changes within the breast
Character of changes (diffuse, focal) •
Number of lesions •
Location (quadrants, sectors) •
Sizes of lesions (three dimensions in mutu-•
ally perpendicular planes)
Echodensity •
Echostructure of lesions •
Contours (even/rough, distinct/vague) •
Mobility of the lesion, discomfort, and •
change in shape with compression
Vascularity •
C. Relations of breast lesion with surrounding
structures (assessment of invasion of breast
carcinoma into surrounding tissues)
D. Condition of regional lymph nodes
If an area suspicious for pathological process
is detected within the breast, moderate compression with the probe is applied. This aims to
assess the mobility of the lesion against the surrounding tissues and its density (deformation)
and to decrease US artifacts resulting from connective tissue elements (e.g., lateral acoustic
shadows).
Ultrasound of the Normal Breast
3
3.1 Ultrasound Anatomy of the Breast
Normal anatomy and individual features of the
breast and regional lymph nodes, as well as it
physiological conditions, are to be considered at
the examination.
Each breast is located on the anterior surface of the chest, on the pectoral fascia and
pectoralis major muscle between parasternal
and anterior axillary lines with the nipple on
middle-clavicular line (Fig. 3.1 ) The level of
its fi xation to the thorax corresponds to II–VI
ribs and the diameter of fi xation area ranges
from 12 to 15 cm.
The size and shape of the breast are variable
and can change with age. Ordinary breast volume
is 200–300 sm 3 .
Breasts originate from the fourth pair of lactiferous points. The development starts during
the fourth week of gestation with the growth of
a basic milk streak. Milk lines, or “ventral epidermal ridges,” are seen by the sixth week of
the embryo’s life. Glands and their ducts develop separately. The development progresses in
women, while in men, the progress stops. Some
people have several pairs of breast germs within
milk lines, although not all of them develop completely after birth.
The fragments of glandular tissue, which are
located separately from the normal breast, form
additional breast lobes. They can be more often
detected in axillary areas, rarely along parasternal lines, or in subclavian areas.
The nipple is located in the center of the breast
and implicates muscular and epithelial tissues. It
is surrounded with the areola – a pigmented skin
area with multiple sweat glands.
Breast consists of the adipose, glandular, and
connective tissues bordered by anterior and posterior leaf of super fi cial fascia of the thorax
(Fig. 3.2 ).
Glandular tissue of the breast is covered with
a super fi cial layer subcutaneous fat. Its thickness
depends on the age and constitution of the woman.
Adipose tissue can be also observed as fatty
lobes, which are incorporated into glandular tissue and surrounded with connective tissue fi bers.
Breast capsule is formed by connective tissue that produces septa (Cooper’s ligaments),
thus forming the breast “skeleton” and maintaining structural integrity. In places of fi xation
of Cooper’s ligaments to glandular tissue, there
appear prominences called crests of Duret.
Connective tissue is also included into the structure of fi brillar tissue between glandular elements
and in the walls of lactiferous ducts. With years,
along with the beginning of involution, Cooper’s
ligaments become denser and surround areas of
fatty tissue, thus forming fatty lobes.
Breast parenchyma consists of alveolar- tubular
complexes, the latter united in lobules and then in
lobes, which tend to integrate together locating
radially in relation to the nipple. Terminal ducts
lobular units are the basic functional units of the
breast that produce milk. During pregnancy and
lactation, the terminations of ducts develop acinar structures, which produce milk, and atrophy
A.N. Sencha et al., Breast Ultrasound,
DOI 10.1007/978-3-642-36502-7_3, © Springer-Verlag Berlin Heidelberg 2013
27
28
3 Ultrasound of the Normal Breast
Anterolateral
dissection
Pectoralis
major muscle
Serratus anterior muscle
External
abdominal
oblique muscle
Clavicle
2nd rib
Pectoralis
major
muscle
Pectoral
fascia
Intercostal
muscles
Fat
Gland lobules
Suspensory
ligaments
(of Cooper)
Areolar
glands
Areola
Nipple
Lactiferous ducts
Ampulla
Intercostal
vessels
and nerve
Lung
6th rib
Sagittal section
Fig. 3.1 Normal breast anatomy (N.F. Netter 2006 )
by the end of feeding period. There are several
generations of lactiferous ducts ending with subsegmentary and segmentary ducts and lactiferous
sinus (Fig. 3.3 ).
Suspensory ligaments (of Cooper)
Ampulla
Lactiferous duct
Gland lobules
Fat
Terminal ducts starting from every lobule run
into ducts of the second generation (intralobar),
the latter running into the ducts of the third generation (central ducts located in subareolar area).
293.2 Types of Ultrasound Picture of the Normal Breast
Pectoralis major
Pectoralis minor
Cubcutaneous fat
Breast lobules
Lactiferous ducts
Nipple
Connective tissue
Ribs
Glandular tissue
Adipose tissue
Fig. 3.2 Breast anatomy
Lobule
Intralobular
terminal duct
Extralobular
terminal duct
Subsegmentary ducts
(3 generation)
Main lactiferous duct
(1 generation)
Lactiferous sinus
Segmentary ducts
(2 generation)
Fig. 3.3 Lactiferous ducts
Before draining to the nipple, the major ducts
form lactiferous sinus, in which supposedly milk
accumulates between breastfeeding sessions.
The breast is highly vascular and is supplied
by the branches of the internal thoracic, subclavian, axillary, and intercostal arteries that form
the rete of anastomoses predominantly in subareolar area (Fig.
3.4 ). The venous rete accompa-
nies corresponding arteries and arterioles.
Breast innervation is provided by the branches
of thoracic, humeral, and intercostal nerves
( Bazhenova et al. 1985 ) .
The lymphatic system is presented by intramammary and abducent lymph ducts and re gional
lymph nodes, the latter conferring axillary, subclavian, supraclavicular, pectoral, and substernal
groups (see Chap.
8 ). Intramammary lymph
ducts form a complex rete with anastomoses and
plexuses. There are some out fl ow lymph tracts
from breast: axillary (more than 90 %), subclavian, parasternal, retrosternal, intercostal, epigastric, and cross way to the other side (Trufanov
et al., 2009 ) .
3.2 Types of Ultrasound Picture
of the Normal Breast
US signs of breast abnormalities are a consequence
of certain morphological changes. US image of
the normal breast is quite variable and depends,
fi rst of all, on the age of the patient and the phase
of menstrual cycle in fertile women. Variability
of US picture also is the result of anatomic and
constitutional features of women and interrelation
of fatty, glandular, and connecting tissues.
In fertile women, US, as a rule, assesses the sta-
tus of the following breast structures (Fig. 3.5 ):
Subcutaneous adipose layer •
Super fi cial leaf of the fascia •
Parenchyma (glandular tissue) •
Lactiferous ducts •
Cooper’s ligaments •
Nipple •
Back leaf of the fascia •
Vascular pattern of the breast (vascularity) •
Retromammary space •
Regional lymph nodes •
The possibility to assess the condition of the
breast skin depends on the frequency of US probe
and the class of US scanner.
Normal skin is imaged as homogeneous
echogenic layer of 0.5–7 mm thickness. Prior
to puberty and in early fertility, the thickness of
the skin usually ranges from 0.5 to 2 mm. The
skin thickness reaches 2–4 mm in premenopause, postmenopause, pregnancy, and lactation
( Zabolotskaya and Zabolotsky 2005 ) .
In fl ammatory process, condition after radiation
therapy, and postoperative edema are accompanied
30
3 Ultrasound of the Normal Breast
a.axillaris
a. thoracica
lateralis
Fig. 3.4 Breast vessels
a.subclavia
with thickening and rough echostructure of the
skin. The echodensity, as a rule, decreases. Irregular
anechoic fl uid collections may be observed in
some cases. The margin between the skin and subcutaneous fat is not always possible to differentiate with 5–7.5 MHz probe. On the contrary, the
probes with the frequency of 10 MHz and higher
permit clear differentiation of super fi cial and profound surfaces of derma of breast skin.
Subcutaneous fat . Adipose tissue is character-
ized with decreased or normal echodensity and
homogeneous-enough structure with linear echogenic incorporations, which often exhibit vague
acoustic shadows (Fig. 3.6 ). The thickness of the
adipose layer depends on the patient’s constitution but, as a rule, increases with age.
In young women, the adipose tissue is presented by a thin layer between the skin and glandular tissue. With age, after pregnancies and
childbirths, the thickness of this adipose layer
increases accompanied with a little increase in
echodensity. In postmenopause with the beginning of mammary involution, the adipose tissue
becomes more irregular due to the development of connective tissue, which is de fi ned as
echogenic linear structures. Cooper’s ligaments
a.mammaria
interna
a.intercostalis (3–7)
become thicker and often form adipose lobules
with lateral acoustic shadows. Fibrous and involutional changes in the breast with large number
of these acoustic shadows negatively affect the
quality of imaging of deep structures and detection of abnormalities, especially small-sized
lesions.
The anterior (super fi cial) leaf of the fascia is
often distinctly observed as an echogenic line
that separates subcutaneous fat from breast parenchyma (Fig.
Parenchyma (glandular tissue) normally looks
like a layer with slightly decreased echodensity
and irregular echostructure. The anterior contour
of breast parenchyma in fertile women has protrusions in the places of fi xation of Cooper’s
ligaments.
In anatomical terms, glandular lobule and glandular lobe are distinguished. Nevertheless, owing
to the fact that glandular lobules and lobes have no
actual capsule, US fails to differentiate them.
Depending on the age, endocrine status,
and ratio of glandular and adipose tissues in
the patient, the echodensity of glandular tissue can vary from decreased to increased. The
echodensity of parenchyma can also change
3.7 ).