Diagnostic ultrasound ( PDFDrive )

CHAPTER 21 The Breast 771
Infected duct
Infected duct
A
B
FIG. 21.16 Duct Wall Hyperemia in Acute Periductal Mastitis. (A) Gray-scale image shows uniform isoechoic wall thickening in the inlamed
or infected duct (arrow). The noninlamed ectatic duct just to the right has a normal, thin, echogenic wall. (B) Color Doppler sonogram shows
marked hyperemia of the wall and tissues around the inlamed duct. The vessel is oriented parallel to the wall.
Ectatic ducts, like cysts, oten contain echogenic secretions
or blood that can be diicult to distinguish from intraductal
papillomas or DCIS by gray-scale imaging alone. Ballottement
of ectatic ducts that contain difuse low-level echoes can cause
the echoes to slosh back and forth within the duct. his can be
appreciated on real-time gray-scale imaging or cine clips and
can be documented on color Doppler sonography as well. he
secretions tend to move posteriorly during compression and
anteriorly during compression release, creating color signals of
opposite color. Demonstrating such a “color swoosh” documents
that the internal echoes are caused by inspissated secretions or
blood rather than tumor. It is important that the color signal
ills the duct because echogenic blood from an intraductal papillary
lesion can lead to a color swoosh, but the underlying papillary
lesion will cause a defect in the color signal. As with intracystic
papillary lesions, intraductal papillary lesions are oten vascular
enough to have a demonstrable vascular stalk on color Doppler
sonography (Fig. 21.15B). his helps to identify intraductal
papillary lesions and to distinguish them from echogenic lipid
or debris layers within the duct.
Doppler may also be useful to evaluate acute breast pain by
helping to reveal an acute inlammatory etiology. Acutely inlamed
cysts and acute periductal mastitis are the most common causes
for this pain. he normally thin, echogenic wall of an acutely
inlamed cyst or duct becomes thick, isoechoic, and hyperemic,
which can be easily demonstrated by color or power Doppler
ultrasound (Fig. 21.16). In comparison, the walls of noninlamed
cysts and ducts have no demonstrable low on color Doppler
sonography. he direction in which the vessels course within
the walls of inlamed cysts and ducts difers from the orientation
of vessels that feed intracystic or intraductal papillary lesions.
Vessels that lie within the walls of inlamed ducts or within the
periductal tissues course parallel to the duct wall because they
are feeding and draining the duct wall and periductal tissues.
Vessels that feed intraductal papillary lesions are oriented perpendicular
to the axis of the duct wall because the vessels are
merely passing through the wall to feed a lesion inside the duct.
Doppler ultrasound and other imaging indings in acutely
inlamed or infected peri-implant capsules are similar to those
in acutely inlamed cysts or ducts.
Doppler sonography can be helpful in assessing lymph nodes
that are not normal but have nonspeciic imaging indings that
prevent determination of whether the node is merely inlamed
or contains metastasis. he histologic and biologic behavior of
lymph node metastases is usually identical to that of the primary
lesion. A vascular primary tumor will tend to have a vascular
lymph node metastasis. If the spectral waveforms obtained from
the center of the primary are high impedance and have high
and sharp systolic peaks, the waveforms obtained from lymph
node metastases from that primary will have similar waveforms.
Conversely, inlamed or reactive lymph nodes will usually have
low-impedance waveforms with low, rounded systolic peaks. he