Superficial structures: Breast, abdominal wall, and musculoskeletal sonography

Superficial structures: Breast, abdominal wall, and musculoskeletal sonography

abdominal hernia

protrusion of peritoneal contents through a defect in the abdominal wall.

Achilles tendon

attaches the gastrocnemius and soleus muscles.

smallest functional unit of the breast.

anisotropy artifact

hypoechoic sonographic artifact caused when the ultrasound beam is not perpendicular to the fibrillar structure of a tendon.

a synovial cyst adjacent and posterior to the knee joint.

Barlow maneuver

determines if hip can be dislocated. Hip is flexed and the thigh adducted while gently placing posterior pressure on the femoral head.

a fibrous sac found between the tendon and bone; lined with a synovial membrane and secretes synovial fluid; facilitates movement of the musculoskeletal structures.

Cooper ligament

strands of connective tissue serving as a support structure of the breast; provides shape and consistency to the breast parenchyma.

Development Displacement of the Hip (DDH)

preferred term to describe the abnormal relationship of the femoral head to the acetabulum; a congenital or acquired deformation or misalignment of the hip joint.

a small filamentous fiber that is often a component of a cell.

fibrocystic disease

the presence of a single or multiple palpable cysts in the breast.

a cyst caused by obstruction of a lactating duct.

small tumor or fluid collection that can occur at the connection of any tendon

an abnormal enlargement of a male breast or breasts.

lactiferous duct

one of many channels that carry milk for the lobes of each breast to the nipple.

lactiferous sinus

an area of enlargement in a lactiferous duct near the areola.

a flexible band of fibrous tissue binding joints together; provides flexibility to a joint.

a midline tendon of the anterior abdominal wall extending from the xiphoid process to the symphysis pubis.

a collection of lobules within the breast parenchyma; approximately 15 to 20 lobes per breast.

the simplest functional unit of the breast.

breast parenchyma lying within the superficial fascia.

Morton’s neuroma

a nonneoplastic fusiform enlargement of a digital branch of the medial or lateral plantar nerves.

tissue composed of fibers and cells that are able to contract, causing movement of the body parts or organs.

musculoskeletal system

consists of all the muscles, bones, joints, ligaments, and tendons that function in the movement of the body and organs.

Ortolani maneuver

relocates the femoral head within the acetabulum. Hip is flexed and abducted while gently pulling anteriorly. Demonstrates whether the dislocated hip is reducible.

rectus abdominis muscle

one of a pair of anterolateral abdominal wall muscles located lateral to the linea alba.

retromammary zone

located between the posterior margin of the mammary zone and the pectoralis muscles.

a painful wrenching or laceration of the ligaments of a joint.

to injure or impair by overuse or overexertion; wrench.

synovial sheath

double-walled tubular structures surrounding some tendons.

bands of dense, fibrous connective tissue that attach muscle to bone.

term used to describe degenerative changes in a tendon without signs of tendon inflammation; associated with overuse injuries.

terminal ductal lobular unit (TDLU)

small lobular unit formed by the acini and the terminal ducts.

a test used to evaluate the integrity of the Achilles tendon where the toes are pointing down while squeezing the calf.

Physiology

Function of the breast

• Produces and secretes milk.

Function of the anterior abdominal wall

• Movement of the torso.

Function of the musculoskeletal system

• Movement of body parts and organs.

The breast

Breast anatomy and location (fig. 15-1)

Terminal ductal lobular unit

• Formed by the acini and terminal duct.

• Several terminal ductal lobular units join to form a breast lobe.

• Origin of nearly all breast pathology.

• Diameter should not exceed 2 mm.

Lobe

• 15 to 20 lobes per breast.

• A major duct courses within each lobe toward the nipple.

Lactiferous duct

• Contained within each breast lobe.

• Courses toward the nipple.

• Enlarges at the areola.

• Lined with epithelial cells.

• Diameter should not exceed 3 mm.

Fibrous planes of the breast

Skin

• Composed of epidermis and dermis layers.

• Measures 2 to 3 mm in thickness.

Subcutaneous fat layer

• Premammary layer.

• Composed of fat and connective tissue.

• Located between the skin and the mammary zone.

• Contains Cooper ligaments.

Cooper ligaments

• Connective breast tissue providing a “skeletal” framework for the breast.

• Located within the subcutaneous layer of the breast.

• Course between the layers of the superficial fascia.

Superficial fascia

• Lies within the subcutaneous fat anterior to the mammary zone.

Mammary zone

• Breast parenchyma lying within the superficial fascia.

• Composed of epithelial and stromal tissue.

• Located between the subcutaneous fat and retromammary space.

Retromammary space

• Houses the deep fascia.

• Composed of small fat lobules.

• Located between the posterior margin of the mammary zone and the pectoral muscles.

Deep fascia

• Deep layer of the superficial fascia.

• Located within the retromammary space.

Pectoralis muscles

• Muscular fascia surrounding the chest muscle.

Pectoralis major muscle

• Located between the retromammary space and pectoralis minor muscle.

Pectoralis minor muscle

• Located deep to the pectoralis major muscle and anterior to the rib cage.

Breast vasculature

Arterial supply

• Lateral thoracic and internal mammary arteries.

• Lateral thoracic artery arises from the axillary artery.

• Internal mammary artery arises from the subclavian artery.

Venous system

• Superficial veins lie deep to the superficial fascia.

• Superficial veins of the right and left breast communicate.

• Deep veins drain into the internal mammary, axillary, subclavian, and intercostal veins.

• Lymph vessels generally course parallel with the venous system.

Congenital breast anomalies

• Amastia—complete absence of one or both breasts.

• Athelia—complete absence of the nipple.

• Amazia—absence of the breast tissue with presence of the nipple.

• Nipple inversion—nipple inverts inward.

• Polymastia—accessory or supernumerary breast.

• Polythelia—accessory nipple; most common breast anomaly.

Sonographic appearance of the breast

• Skin line appears hyperechoic.

• Superficial and deep fascial planes appear hyperechoic.

• Glandular breast parenchyma appears moderately hyperechoic.

• Fat breast lobules should demonstrate a medium-gray echo pattern.

• Retromammary layer appears hypoechoic.

• Pectoralis muscles appear moderately hyperechoic.

• Cooper ligaments appear as hyperechoic linear structures; may demonstrate posterior acoustic shadowing.

• Lactiferous ducts appear as nonvascular, anechoic tubular structures coursing toward the nipple.

Technique

Preparation

• No preparation.

Examination technique and image optimization

• 7.5-MHz or higher linear transducer to obtain optimal resolution for penetration depth.

• Proper image depth with focal zone(s) at or below the place of interest.

• Gain settings demonstrating breast fat as a medium shade of gray and a simple cyst as an anechoic mass.

• Increase in dynamic range setting.

• Sufficient imaging depth to visualize structures immediately posterior to the region of interest.

• Harmonic imaging can be used to reduce artifactual echoes within anechoic structures.

• Spatial compounding can be used to improve visualization of structures posterior to a highly attenuating structure.

• Proper Doppler controls for low-flow velocity (pulse repetition frequency [PRF], gain, wall filters).

• Patient is generally placed in a right or left posterior oblique position.

• Standoff pad should not exceed 1.0 cm in thickness.

• Evaluation and documentation of breast parenchyma in two imaging planes, remaining perpendicular to the chest wall.

• Proper annotation of the image location and scanning plane.

• Images are generally labeled by quadrant and/or the face of a clock.

• Distance from the nipple is described as 1, 2, or 3 (1 is closest to nipple).

• Depth of the area of interest is described as A, B, or C (C is closest to the chest wall).

• Documentation and measurement of any abnormality in two scanning planes should be included.

• Color Doppler imaging to evaluate abnormalities for internal and peripheral flow.

Indications for a breast examination

• Palpable lump.

• Breast inflammation.

• Evaluate mass from a previous medical imaging study (i.e., mammogram).

• Ultrasound-guided interventional procedure.

• Evaluate augmented breast.

• Evaluate male breast parenchyma.

• Serial evaluation of a benign lesion.

Benign Breast Pathology

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Tags: Abdomen, Obstetrics and Gynecolo, Sonography Exam Review Physics

Jun 15, 2016 | Posted by admin in GYNECOLOGY | Comments Off

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PATHOLOGY FINDINGS	ETIOLOGY	CLINICAL FINDINGS	SONOGRAPHIC FINDINGS	DIFFERENTIAL CONSIDERATIONS
Cyst	Obstruction of a duct Infection Common around 35-50 yrs of age	Asymptomatic Breast pain or tenderness Palpable mass	Anechoic round or oval mass Smooth, thin wall margins Posterior acoustic enhancement No internal vascular flow Compresses with transducer pressure Mass does not breach fascial plane(s) May demonstrate internal echoes	Lactiferous duct Fibroadenoma Carcinoma
Cystosarcoma phyllodes	Uncommon benign fibroepithelial neoplasm May undergo malignant transformation	Sudden onset of a palpable nontender breast mass Mobile mass	Oval mass demonstrating a low- to medium-level echo pattern Unilateral mass May demonstrate cystic spaces within the mass Smooth wall margins Width of mass is larger than the height Mass does not breach fascial plane(s) Internal blood flow may be demonstrated	Complex cyst Fibroadenoma Carcinoma Normal breast fat
Fibroadenoma	Tumor composed of dense epithelial and fibroblastic tissue Influenced by estrogen levels	Asymptomatic Palpable nontender breast mass Mobile mass Firm or rubbery on palpation	Solid oval-shaped breast mass Low- to medium-level echo pattern Posterior acoustic enhancement Mass does not breach the fascial plane Width of mass is larger than the height Can degenerate or calcify Internal blood flow may be demonstrated	Complex cyst Normal breast fat Carcinoma
Fibrocystic disease	Presence of palpable breast cyst(s) Not generally associated with future development of breast carcinoma	Painful or tender breasts frequently 7-10 days before the start of menses Increase in pain intensity closer to the start of menses	Hyperechoic breast parenchyma Dense breast tissue Prominent ducts Numerous breast cysts	Multiple breast cysts Mastitis
Hamartoma	Proliferation of normal tissues	Asymptomatic Palpable mass	Heterogeneous complex mass Smooth wall margins May demonstrate posterior acoustic shadowing Mass does not breach fascial plane(s) Mass compresses with moderate transducer pressure	Complex cyst Carcinoma Fibroadenoma
Galactocele	Obstruction of a lactating duct	Palpable retroareolar mass	Round or oval hypoechoic retroareolar mass Smooth wall margins Posterior acoustic enhancement	Fibroadenoma Complex cyst Abscess
Gynecomastia	Abnormal proliferation of ductal, glandular tissue, and stroma Increased amount of subcutaneous fat Hormone disorders Endocrine disorders Neoplasms	Abnormal enlargement of the male breast(s) Painful or tender breast(s)	Hypoechoic to hyperechoic tissue beneath the areola Ducts converging toward the areola Increased amount of breast fat Unilateral or bilateral	Neoplasm Mastitis
Lipoma	Mature adipose tissue	Soft, mobile mass	Homogeneous hyperechoic mass within the subcutaneous fat Oval in shape Smooth wall margins May appear similar to breast fat	Glandular breast tissue Fibroadenoma Complex cyst
Mastitis