BREAST

Breast is a modified sweat gland that is located in the superficial fascia of the abdominal wall.

 

Normal Anatomy- the surface of the breast is dominated by the nipple and the surrounding areola.

  Location- the major portion is situated between the second and third rib superiorly, the sixth and seven costal cartilage inferiorly, anterior axillary line laterally, and the sternal border medially.  

  Surrounding muscles and supporting ligaments: pectoralis major is posterior to retromammary layer and pectoralis minor is cover by pectoralis major.

   Lymphatic and nodes are similar to blood capillaries. They are abundant and empty into lymph nodes. Axillary lymph are located in in axilla, along thoracic wall and they are the main drainage of the blood. Pectoral nodes are between pectoralis major and  minor. Parasternal nodes are along thoracic vessels on internal surface of anterior abdominal wall. Subcutaneous are near areola, across middle to clavicle , downward to abdominal wall.   

  Layers of tissue types are:

  -subcutaneous layer that is thin and contains fatty tissue and Cooper’s ligaments.

 

  - mammary layer that is a thick functional portion of the breast. It contains supportive tissue:

   * 15-20 lobules that radiate from the breast

   *lactiferous ducts that carry milk from acini to the nipple

   *terminal ductal lobular unit that is made up of acini and terminal ducts

   *fatty tissue that is between the lobes

   *Cooper’s ligaments that extend from the retromammary fascia to the skin and provide

    Support

 

 -retromammary layer that is thin. It contains fatty tissue and Cooper’s ligaments
 
 

 

   Changes in breast tissue with age (density/fatty) Young women have dense fibrous breasts, that are easy to evaluate US, and difficult to evaluate with mammography. Older women have increase fat that is easy to evaluate on mammography and difficult on US.

  Parts of the breast:

 Lobes are collection of lobules. There are 15 to 20 lobes in each breast, that very in size. When women are lactating half will become functional. There are pyramidal in shape, radiating from areola with apex pointing toward areola.

 Lobules are functional unit of breast. One lobule includes one gland and a duct.

Ducts of lobules merge to form larger ducts in the lobe that are lactiferous ducts. Lactiferous ducts converge toward nipple and dilate to form lactiferous sinuses that function as milk reservoir. Beyond sinuses each duct gets smaller; they have numerous branching and become continuous with the alveoli. Normal lactiferous ducts may be seen on US.

 Alveoli (acini) are grape- like clusters in the lobes that produce milk.

  Vascular supply: the main arterial supply to the breast comes from the internal mammary (central and medial portions) and the lateral thoracic arteries (upper outer quadrant).

Venous drainage is mainly provided by superficial veins.

 

Protocols utilized: patient in supine or slightly oblique position, transducer 7.5 MHz or grater are used (usually 10-15).

          Quadrant approach divides breast in right / left, lower /upper and inner/ outer quadrants.

         Clock approach uses the clock face as guidance to mark the breast. Directly above the nipple on either breast is 12 o’clock. Right medial breast and left lateral breast are 3 o’clock. Directly below the nipple bilaterally is 6 o’clock, and right lateral breast and left medial breast are 9 o’clock.

         Zone approach divides the breasts into the three concentric circle, with the center being the nipple. The first ring circles one third of the breast tissue , just outside the nipple is zone 1. The second ring is about two thirds of the breast surface from the nipple, or zone 2. The final ring is breast periphery or zone 3.

          Palpable mass orientation is determined by aligning the transducer with the longest axis of the lesion and identifying whether the long axis is oriented in a radial or antiradial plane.

         Annotation –labeling sonographic images of the breast is extremely important. The quasigrid pattern is mostly used. This views the breast as a clock face. 

 

 BREAST PATHOLOGY -USA

  Margin : benign lesion usually have smooth , rounded margins. Malignant tumors are aggressive and tend to grow through tissue via finger-like extention.

 Disruption of breast Architecture : benign tumors are usually slow growing and do not invade surrounding tissue. They tend to grow horizontally within the tissue planes, parallel to the chest wall. Malignant lesion, on the other hand , tent to grow right through the normal breast tissue. As malignant masses enlarge, they may cause retraction of the nipple or dimpling of the skin .

Echo pattern : lesion that appear isoechoic to breast parenchyma ,or brighter then fat are usually benign. Malignant lesions tent to be highly hyoechoic relative to fat and usually have weak internal echoes. They are often associated with dense shadowing , making the lesion difficult to penetrate. Microcalcifications  within a solid mass are associated with breasth malignancy.

BREAST PATHOLOGY-BENIGN         

1.  Simple Cyst are commonly seen in women 35-55 years of age. They are well defined, anechoic and they can change with the menstrual cycle. They can cause pain if they grow rapidly.

2.  Fibrocystic Condition – fibrocystic changes produce histologic alternations in the terminal ducts and lobules of the breast in both epithelial and connective tissue. Those changes are accompanied by pain or tenderness in the breast and represent normal physiological process of the breast that is caused by normal female hormonal cycle. Clinical signs and symptoms of FCC include the lumps and pain that the patient feels with every monthly cycle. 

3.  FIbroadenomas are the most common breast tumor that primarily occurs in young women. They can be uni- o bilateral. They are firm, rubbery, freely mobile, and clearly delineated from surrounding breast tissue. They have smooth rounded margin, low –level homogeneous echoes and may have posterior enhancement. 

4. Cystosarcoma Phylloides is rare predominantly benign tumor, can be malignant too. It is more common in older women and usually unilateral.

5.  Gynecomastia is most common breast disease in male. It  is uni- or bilateral breast enlargement . It is idiopathic and associated with excess estrogen, increased age and testicular failure. On US the fibroglandular tissue is enlarged but normal.  

6.  Infectious Processes results from infection, trauma, and mechanical obstruction in the breast ducts, or other condition. It often occurs during lactation, beginning in the lactiferous ducts and spreading via the lymphatics or blood. It is also called acute mastitis. It causes an enlargement, reddened , tender  breast, usually one area . Diffuse mastitis results when infection effects the entire breast.
 
 
 

MALIGNANT LESIONS

          Basic facts on Breast Ca –cancer of the breast is of two types : sarcoma ,that arise from supportive and connective tissue ; and carcinoma that arise from epithelial tissue. Sarcomas tend to grow rapidly and invade fibrous tissue.

            Clinical signs and symptoms of possible breast cancer:

 New or growing dominant, discrete breast lump

  • Hard, gritty, or irregular surface
  • Usually (not always) painless
  • Does not fluctuate with hormonal cycle
  • Different from “lumpy” breast texture

Unilateral single-duct nipple discharge

  • Spontaneous, persistent; serous or bloody 

Surface nipple lesions

  • Nonhealing ulcer
  • Facial irritation

New nipple retraction

New focal skin dimpling or reactions

Unilateral new or growing axillary lump

Hot, red breast
 

              

      Diagnostic Tools for evaluation and screening are : breast self-examination (monthly beginning at age 20) , clinical breast examination by a health care provider ( ages 20-39 every 3 years and ages 40 on yearly), screaming mammography (yearly starting at age 40).

                   Signs on mammogram suspicious for malignancy

           Risk Factors :

Female gender,

Increasing age ,

Family history of breast cancer –first degree relative (mother, sister, daughter), associated cancers (ovarian, colon, prostate), premenopausal breast cancer,

Biopsy –proven atypical lesion- lobular neoplasia , atypical epithelial hyperplasia

Prolonged estrogen effect – early menarche

Late menopause

Nulliparity

Late first pregnancy

 

 

           MALIGNANT CONDITIONS

                            

                   A.  Medullary is a densely cellular tumor that contains large, oval, or oval tumor cells .It is usually well-circumscribed mass, with the center frequently necrotic , hemorrhagic , and cystic. It is rare, less than 5 % of breast cancer . It usually affects women younger than fifty. It is well define, often large, and resembles the fibroadenoma.

                        B.  Papillary Cell Carcinoma is a tumor that initially arises as an intraductal mass. The early stage of papillary carcinoma is noninvasive. It is rare and the earliest clinical sign is bloody nipple discharge. Occasionally, a mass can be palpated as a small, firm and well circumscribed and may be mistaken for fibroadenoma. Nodules of blue or red discoloration may be found under skin with central ulceration. It typically has a more favorable prognosis than other types of carcinoma. 

                   C.  DCIS- ductal carcinoma in situ is also known as intraductal carcinoma .It is characterized by cancer cells that are present inside the ducts but have not yet spread through the wall of the ducts into the fatty tissue. Because these are only in ducts they have 100% cure rate.

                   D.  IDC (include Tubular Ca) is most common breast cancer -80% of breast cancers. It is similar to DCIS, it starts in ducts but it spreads in fatty tissue and can metastasize via the bloodstream or lymphatic system. Tubular carcinoma represents an extremely well-differentiated form of invasive ductal carcinoma. It occurs in women with an average age of 50. It has a good prognosis. It typically has poorly circumscribed margins and a hard consistency.    

                   E.  LCIS- lobular carcinoma in situ is not considered a cancer because it has low malignant potential. It is often refer as lobular neoplasia and it is classified as a precancerous growth that begins in lobule.it is confined to the gland and does not penetrate through the wall of the lobule. Women with LCIS are at higher risk of developing invasive cancer later on.

                   F.  ILC –invasive lobular carcinoma begins in lobule and extends into the fatty tissue of breast. It has potential to metastasize and spread to other parts of the body. It is second most invasive cancer-10% to 15%. It is often bilateral, multicentric, or multifocal.
 
 

 

ULTRASOUND –GUIDED INTERVENTIONAL PROCEDURES  

 

 Cyst aspiration – is a common technique that removes the fluid from the cyst to be analyzed. The cystic fluid is usually “straw –colored” when it is withdrawn. The main two indications are a symptomatic cyst (palpable and painful) and hypoechoic lesions not meet cyst criteria.  Aspiration can determinate if the cyst is simple, complex or solid mass.

Preoperative localization technique uses US guidance for a placement of the percutaneous needle wire assembly for preoperative localization of a no palpable breast lesion for surgical excision.

Core biopsy –is accurate , safe ,widely technique used to help diagnose benign or malignant masses. Premedication is usually not necessary . Usually done by using automated gun that retracts the large core of tissue , it uses single pass and it is easy to used.

Vacuum – Assisted Needle Biopsy is a new technique, it minimally invasive procedure that allows the removal of multiple large tissues samples with a single insertion of the needle. A special biopsy probe and large gauge cutting needle are used. Under US, the needle is inserted immediately posterior to tumor. Once sampling is initiated, a vacuum pulls the tumor into the opening on the needle, and a rotating cutting blade slice the tissue. This biopsy allows multiple tissue samples to be taken with minor rotation of the needle. 
 
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