Diagnostic ultrasound ( PDFDrive )

798 PART III Small Parts, Carotid Artery, and Peripheral Vessel Sonography
recommended for difuse unilateral or bilateral breast pain that
may or may not be cyclic in nature.
Palpable Abnormality
he speciic goal of targeted sonographic evaluation of palpable
lumps is either (1) to ind a malignant lesion that has been
obscured by surrounding dense tissues on the mammogram or
(2) to ind normal or deinitively benign causes of the lump that
do not require biopsy or short-interval follow-up.
Ultrasound is most useful when there is dense tissue in the
area of the palpable lump on mammography. Lesions that do
not contain calciications may be obscured by surrounding dense
tissues on mammography. Sonography has much less to contribute
to cases with a background of predominantly fat and only fatty
density in the area of the palpable lump on mammography. It
is unlikely that the mammogram missed anything signiicant,
and the palpable lump is most likely to be either a fat lobule or
a benign lipoma in such cases. he rare exception to this general
rule occurs in cases of pea-sized or smaller palpable lumps when
the skin line is overpenetrated on the mammogram and thus
cannot be appreciated. hese patients may have a tiny, supericial
lesion just under the skin that is not adequately shown on the
mammogram. his situation is much less common on digital
mammograms with current tissue equalization techniques. Should
the palpable lump be an asymmetric mixture of fat and water
density in a predominantly fatty breast, sonographic evaluation
should be aggressively performed, because this could represent
a malignancy. When a palpable area correlates with a suspicious
mass on ultrasound, the ultrasound evaluation can be used to
help target the area for subsequent biopsy.
When used to conirm that a palpable abnormality is benign,
ultrasound can help avoid biopsy or additional imaging follow-up.
Should the mammogram reveal a inding in the area of clinical
concern, ultrasound can be used to demonstrate whether the
inding is benign such as a simple or complicated cyst. Should
the mammogram be normal in the area of clinical concern,
targeted ultrasound to that location should be performed as
well. If only normal breast tissue is seen, then there is a high
probability that the area is not malignant. Several studies have
now shown an extremely high (≥99%) negative predictive value
for the combination of normal mammography and normal or
benign ultrasound indings. 58,59 hat being said, should a patient
have a new or increasing palpable area that is clinically suspicious,
the clinicians can perform a blind biopsy of the area to
conirm that it is not malignant. Accordingly, a notation for
clinical follow-up is important as part of the management
recommendations.
If sonography is to be efective at evaluating a palpable
abnormality, it is essential that the abnormality be simultaneously
palpated while being scanned. he image should be annotated
with the word “palpable.” An image could be acquired during
the act of palpation wherein the inger is documented in the
image (Fig. 21.57). Simply showing that normal tissue or a benign
cyst exists in the same quadrant is insuicient proof that it is
the cause of the palpable lump. For large lesions in compressible
breasts, the operator can usually slide the nonscanning index
inger under the transducer while scanning. For smaller lesions
and irmer breasts, the index inger may lit the ends of the
transducer so far of the skin that the lesion cannot be scanned
with the inger between the transducer and skin. In such cases,
trapping the lesion between the index and middle ingers and
scanning the lesion while it is trapped may be useful (Fig. 21.58).
For very small and supericial lesions, an opened paper clip can
be used to palpate the lesion during scanning without liting the
ends of the transducer of the skin.
Nipple Discharge
Evaluation of nipple discharge begins with a review of the
symptoms. Bilateral nonspontaneous milky nipple discharge is
more oten associated with hormonal changes that are either
physiologic or are associated with prolactin-producing tumor,
and imaging evaluation of the breast is not needed.
Finger
Palp
Finger
KB
L 1230 areolar TR
Left breast area of palp per pat.
1 N5 AR
Right breast palp area
FIG. 21.57 Marking Palpable Lesions During Targeted Diagnostic Sonography Is Critical. Left, Small, simple cyst is palpated with the
nonscanning index inger during imaging. Right, Fibroductal ridge is palpated during scanning.