Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5791_Библиотеки_им_академика_М_И_Перельмана.pdf
313.2 Types of Ultrasound Picture of the Normal Breast
a
b
Fig. 3.5 Normal breast US. ( a ) Grayscale US. ( b ) Graphic
depending on the phase of menstrual cycle.
Proliferative processes decrease the echodensity of glandular tissue.
In young women, glandular tissue is usu-
ally isoechoic or slightly hyperechoic and is
Skin
Subcutaneous fat
Superficial leaf of the fascia
Cooper’s ligaments
Parenchyma
Rib
Retromammary space
Posterior leaf of the fascia
Muscles
observed as a relatively homogeneous uniform
layer. Connective tissue fi bers have small
amount of collagen and are practically invisible against the basic layer. Only in the second phase of menstrual cycle there can arise
32
Fig. 3.6 Normal breast.
Subcutaneous adipose layer
( arrow ). Grayscale US
3 Ultrasound of the Normal Breast
granularity due to echogenic fi elds of glandular tissue against hypoechoic lactiferous ducts
(Fig.
3.8a ).
In reproductive age, the ratio of parenchyma
and stromal component are individual and depend
mainly from constitutional features, endocrine
status, number of pregnancies and childbirths,
and the duration of lactation. The greatest thickness of glandular tissue is registered, as a rule,
in upper-outer quadrants, the least in the inner
quadrants.
With aging, after pregnancies and lactation periods, the thickness of glandular layer decreases.
There appear hypoechoic adipose lobes and echogenic fi elds of fi brous tissue against glandular tissue,
the latter being of increased echodensity (Fig. 3.8b ).
During lactation, the ductal ectasia of various
degree is usually de fi ned (Fig.
3.8c ). Pregnancy
and lactation are associated with signi fi cant
enlargement of the thickness of glandular tissue,
which reaches 25–30 mm, and grainy structure of
the parenchyma.
Fig. 3.7 Normal breast.
Anterior (super fi cial) leaf
of fascia. Grayscale US
333.2 Types of Ultrasound Picture of the Normal Breast
In patients older than 40 years, the number of
glandular lobes decreases and adipose tissue
starts to prevail over the glandular one.
In a postmenopause, the glandular tissue becomes
thin. Its thickness, as a rule, does not exceed 4 mm.
The major part of the breast is usually presented by
multiple adipose lobes, detected as homogeneous
structures of decreased echodensity surrounded
with echogenic rims of connective tissue fi bers
(Fig. 3.9 ).
Accessory breast tissue in the axilla affects
1–6 % of women (Rozhkova 1993 ) . Its typical
location is the anterior boundary of the axilla.
Accessory breast tissue with US is presented by
the same tissue, as the breast in typical location
3.10 ). It can sometimes simulate a patho-
(Fig.
logical lesion.
Cooper’s ligaments are connective tissue
septa, which derive from fascia and follow on
perpendicularly to the anterior surface of the skin.
34
3 Ultrasound of the Normal Breast
a
b
Fig. 3.8 Breast parenchyma. Grayscale US. ( a ) Reproductive age. ( b ) Menopause. ( c ) Lactation period
Fig. 3.8 (continued)
353.2 Types of Ultrasound Picture of the Normal Breast
c
They appear on the US image as thin echogenic
linear structures (Fig. 3.11 ).
They surround adipose lobules and can produce lateral acoustic shadows, hence imitate
breast lesions. The structure of Cooper’s ligaments becomes denser with aging with more
expressed acoustic shadows. Differentiation of
such areas from breast pathology is possible with
polypositional examination.
The image of lactiferous ducts depends on
patient’s age, the phase of menstrual cycle, and
the frequency of US probe. Breast US with linear
5.0–7.5 MHz probe in the fi rst phase of menstrual
cycle normally detects terminal and interlobar
ducts smaller than 2 mm in caliber or fails to differentiate them. The caliber of ducts in subareolar area can reach 3–5 mm. Probes with the
frequency of 10–12 MHz practically always permit detection of interlobar ducts in the fi rst phase
of menstrual cycle, in spite of their diameter does
not exceed 1 mm.
In the second phase of menstrual cycle, the
ducts are usually imaged as an- or hypoechoic
tubular structures directed to subareolar area.
Their caliber, as a rule, is larger than 2 mm
(Fig. 3.12a ). Some days before menses, the
echodensity of ducts decreases to anechoic that
gives the opportunity to differentiate interlobar
and main lactiferous ducts.
During pregnancy, the ducts can be easily imaged, and their caliber exceeds 2 mm.
During lactation period, the diameter of ducts
can reach 3.5–4 mm. They can be observed as
hypoechoic or anechoic tubular structures that
sometimes get colored in CDI and PDI modes
(Fig. 3.12b ).
Main lactiferous duct may exhibit four patterns of branching: magistral (21 %), scattered
(67.1 %), duplicated (7 %), and looped (4.9 %)
(Rozhkova 1993 ) .
In connection with the changes in endocrine
status of a woman with age and in cases of hormone replacement therapy, the difference between
US images of ducts in the fi rst and the second
phases of menstrual cycle decreases.
It is necessary to differentiate the ducts from
blood and lymphatic vessels using CDI, PDI, or
3D reconstruction of the image.
36
Fig. 3.9 Normal breast.
Adipose lobes ( arrow ).
Grayscale US
3 Ultrasound of the Normal Breast
The back leaf of the fascia borders the breast
from the retromammary space and is imaged as
thin homogeneous echogenic linear structure
(Fig. 3.13 ).
The retromammary space contains retromam-
mary adipose tissue (as a rule of decreased
echodensity and irregular echostructure), the
pectoralis major and minor muscles, intercostal
muscles, and pleura (Fig. 3.14 ).
It is not always possible to differentiate
the structures of the retromammary space. It
mainly depends on the class of US scanner, the
frequency of probes, and the experience of US
specialist.
373.2 Types of Ultrasound Picture of the Normal Breast
Fig. 3.10 Normal breast. Accessory breast tissue ( arrow ). Grayscale US and compression sonoelastography
38
Fig. 3.11 Normal breast.
Cooper’s ligaments ( arrow ).
Sonograms. Grayscale US
3 Ultrasound of the Normal Breast
Pectoralis major and minor are de fi ned as
hypoechoic structures isolated with septa. The
echostructure of the ribs depends on the amount
of osteal and cartilaginous component. Therefore,
the echodensity and uniformity of their structure
may vary.
The nipple is normally de fi ned as a roundish
structure of average or decreased echodensity
with comparatively homogeneous structure and
accurate even contours (Fig. 3.15 ).
Sometimes the nipple is accompanied by the
posterior acoustic shadow, which results from
connective tissue structures. It dictates the necessity to examine subareolar area polypositionally
to rule out abnormalities in this area, especially
in cases of inverted or retracted nipples.
Vessels of the normal breast are often impos-
sible to detect with CDI, PDI, or 3DPD (Fig. 3.16 ).
They sometimes may be observed as individual
color spots with linear orientation in longitudinal
393.2 Types of Ultrasound Picture of the Normal Breast
scans. Blood fl ow with pulsed Doppler is characterized by the following parameters: PSV,
10–13 cm/s; EDV, 3–6 cm/s; PI, 1.20; and RI,
0.59 ( Harchenko et al. 1993a, b ) .
It is necessary to notice that normal US pic-
ture of the breast in women of one and the same
age is quite different and depends on several
aspects associated with individual features.
During breast US, it is necessary to compare
the structures of the right and left breasts and
a
assess dynamic changes in US picture in the current cycle phase and in a certain time interval (2–3
months) in the corresponding phase of menstrual
cycle. Complete and correct information about
the breast condition can be obtained taking into
account all features, such as the age, phase of
menstrual cycle, functional, and endocrine status.
According to Zabolotskaya ( 2006 ) , there are
certain types of breast constitution that are differentiated with US: juvenile, early reproductive,
Fig. 3.12 Lactiferous ducts
of the normal breast.
( a ) Grayscale US.
( b ) CDI and PDI
40
Fig. 3.12 (continued)
3 Ultrasound of the Normal Breast
b
premenopausal, postmenopausal, and the gland
during pregnancy and lactation.
The doctor in the conclusion can recommend
repeated US in a speci fi c phase of menstrual
cycle or after a certain period of time to analyze
the changes in pathological process or differentiate it from physiological features.
The standard report of breast US should contain following instances:
1. Information about endocrine status, such as
the day of menstrual cycle in women of
reproductive age, number of years after menopause in women of the postmenopausal period,
data about lactation and its duration, pregnancy and its term, and about recent medical
or spontaneous abortion
2. The tissue (adipose, glandular), which prevails
in the breast. The thickness and structure of
glandular tissue
3. The condition of lactiferous ducts and its
correspondence to hormonal status of the
woman