Diagnostic ultrasound ( PDFDrive )

CHAPTER 21 The Breast 799
Palp area between fingers
1 N1 ARAD
Left breast palp area
FIG. 21.58 Finger Trapping to Document Breast Lesion. Trapping
the palpable abnormality between the index and middle ingers can be
helpful in documenting the cause of the “lump.”
A
B
Discharge that is more concerning for breast malignancy is
unilateral and spontaneous. he discharge may be bloody,
serosanguinous, or clear, although color alone should not lead
one to dismiss the sign. Unilateral nipple discharge is most oten
caused by papillomas; however, carcinoma must be excluded.
Other causes include duct ectasia, benign FCC with communicating
cysts, or an idiopathic cause. Historically, imaging evaluation
of unilateral nipple discharge was primarily with galactography;
however, other tools including ultrasound are now more commonly
used. Ultrasound can be performed during the initial
diagnostic workup or can be used during a second-look evaluation
ater MRI or galactography. 60-62 As a irst-line evaluation, retroareolar
ultrasound is performed to identify an intraductal mass
that may be causing the discharge. Because intraductal papillary
lesions that cause nipple discharge oten lie within the large
mammary ducts under or near the areola, this is the area that
should be targeted for the ultrasound evaluation. 49 Warm room
temperature, warm acoustic gel, and special maneuvers, such as
the two-handed compression maneuver and the rolled nipple
technique, help minimize shadowing that can arise in the nipple
and areola.
Papillomas appear to be isoechoic nodules (less echogenic
than the duct wall) within ectatic luid-illed ducts (Fig. 21.59).
he appearance of papillomas varies with the degree and distribution
of duct dilation, with the diameter and length of the lesion,
and with involvement of branch ducts and TDLUs. In addition,
papillary lesions that afect TDLUs are, by deinition, peripheral
papillomas, regardless of their distance from the nipple. Peripheral
papillomas are at much higher risk for being malignant than
large duct papillomas (Fig. 21.60). However, because ultrasound
characteristics of malignant versus benign papilloma have not
been well established, biopsy is performed on most intraductal
masses and likely papilloma.
Sonography can show causes of nipple discharge other than
large duct papilloma, such as carcinoma, duct ectasia, communicating
cysts, and hyperprolactinemia (Fig. 21.61).
FIG. 21.59 Intraductal Papillary Lesion. (A) Small, ovoid intraductal
papillary lesions that do not expand the duct represent benign large
duct papillomas in more than 98% of cases. (B) Even small intraductal
papillomas typically have a readily demonstrable vascular stalk.
Mammographic Findings
Sonography is the best diagnostic tool for assessing mammographic
abnormalities that do not contain suspicious calciications.
hese mammographic abnormalities range from discrete masses
to one-view asymmetries. It is important to complete the mammographic
workup of these indings and determine the level of
suspicion before beginning the ultrasound evaluation. his
essentially becomes the pretest probability for identifying a
malignancy and will help drive one’s recommendations. Only
in a small percentage of patients will sonography show indings
that are more suspicious than those suggested by mammography.
Completing the mammographic workup initially is most important
for the scenario in which no ultrasound correlate is found
and management must depend solely on the mammographic
evaluation.
When completing the ultrasound evaluation, it is important
to be sure that the sonographic inding explains the mammographic
abnormality, and that there are not two completely
disparate indings—a mammographic inding and a separate and
incidental sonographic inding. To ensure that there is only a
single inding and that the sonographic inding and mammographic
inding are the same, the clinician must rigorously ensure
that the size, shape, location, and surrounding tissue density of
the mammographic and sonographic indings are the same.
Mammographic-sonographic correlation of size, shape, location,
and surrounding tissue density is best made between the craniocaudal
(CC) mammographic view and the transverse
sonographic view because there is little rotation and no obliquity
of the x-ray beam on the mammographic CC view. If a mammographic
lesion can be seen only on the mediolateral oblique
(MLO) view, it is usually best to obtain a true mediolateral (ML)