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126 Cards in this Set

  • Front
  • Back
What is breast ultrasound primarily used for; screening or diagnosis
diagnosis (screening is becoming more popular)
What are the 3 zones of the breast
premammary zone
mammary zone
retromammary zone
What is contained in the premammary zone (AKA subcutaneous zone)
4
SQ fat
suspensory ligaments
blood vessels
skin pathology
What is contained in the mammary zone
5
ducts
fat
fibrous tissue
breast pathology
suspensory ligaments
What is contained in the mammary zone
fat
suspensory ligaments (coopers ligaments)
superficial perctoralis
some breast pathology
What is the appearance of skin on US
hyperechoic
What is the appearance of fat in the breast
hypoechoic (hyperechoic everywhere else)
If a breast is very dense what is the appearance on US
very hyperechoic
Does having dense breast help with ultrasound
yes, the opposite of mammography...having dense breast makes the hypoechoic lesions pop out
What is the appearance of the fat in a LN
it is hyperechoic (exception of the breast)
Describe the findings of a LN on US
oval
circumscribed
hilum hyperechoic (fat)
cortex hypoechoic
may have increased through transmission
What is the doppler findings of a LN
the hilum may have increased flow
What is the appropiate position when performning a breast ultrasound
ipsilateral are underhead
What type of transducer is used for breast US
linear high resolution (7.0mhz)
What is a standoff pad used for
if a lesion is in the skin a stand off pad allows the focal zone to be elevated for better evaluation
What are the two ways to scan the breast
transverse and longitudinal

radial and antiradial (clockwise and counterclockwise)
How is doppler helpful in breast US
determines solid vs cystic

finds hyperemia in infected cyst wall

will find hilar flow in a LN
Why is duplex doppler useful
will help to determine if there is true flow vs noise
Can a cancer look like a cyst
yes that is why it is important to use doppler
What is a pitfall when using doppler to determine if there is flow
if you compress too hard you can eliminate flow that is actually there
In a fatty breast (hypoechoic) is it sometimes difficult to dicern hypoechoic lesions
yes
Besides regular ole doppler what is another technique for determing if a lesion is a mass
power doppler fremitus
How does power doppler fremitus work
pt hum or say 'eee' then normal tissue will vibrate and distiguish from true solid mass.
Does the lesion fill in on power doppler or the normal tissue
the normal tissue will fill in and appear as orange the true lesion will not
Generally speaking for cancers what is the RI centrally and peripherally
high RI centrally
low RI peripherally
If you are having difficulty determining if a lesion is solid or not can you compress it to see if it is a true lesion
yes, fat will compress 30% while a solid lesion will not
What is elastography
this is a new technique which measures the differences in elasticity of tissue
What must be annotated on all images of US
side (right vs left)
clock face position
distance from the nipple
scan plan orientation (trans/long vs rad antirad)
depth of the lesion (optional)
What are the three descriptors for depth
anterior
middle
deep
Hoiw is the distance from the nipple annotated
inner third
middle third
outer third
How is depth annotated in some institutions
A (anterior third)
B (middle third)
C (deep third)
What is the lexicon for describing masses of a breast on US
7
shape
orientation
margin
lesion boundary
echo pattern
posterior acoustic features
surrounding tissue
What is the Birads assessment categories
0 needs additional work up
1 negative
2 benign
3 probably benign
4 suspicious
5 highly suggestive
6 known
What percent chance of breast cancer is there if a pt is birads 3, 4 or 5
<2%
3-94%
>95%
What is the follow up for birads 3
6 month
What is the time interval fu for a birads 3
6 month
What is the time interval fu for birads 1 and 2
1 year
When is US the first line technique for analyzing the breast
Palpable masses:
women less than 30
lactating
pregnant
What are 3 secondary reasons why breast US is used
Further eval of mammographic findings

evaluation of breast implants

Guidance of interventional procedures
What are some other indications for breast imaging that are beginning to come in vogue
Second look US following MR
Suspected breast mets with unknown mets
Evaluate response to therapy and extent of disease
Whole breast US screening for occult cancer
What are 2 reasons why breast US is the 1st line modality for women under 30y
No radiation (younger are more sensitive to radiation)
Dense breast limit mammographic evaluation
When is mammogram needed in a women less than 30
if no US correlate is found to a palpable leesion

A suspicous lesion is found on US and this needs further work up
Besides women under 30 y when is breast US a first line modality
pregnant and lactating women
If a women under 30 gets a mammogram and biopsy reveals a malignant lesion what is the next step
mammography for further evalution of extent of disease
What are the US characteristics of a breast cyst
anechoic
round or oval
sharply marginated
thin edge shadow artifact
posterior acoustic enhancement
negative doppler
What are the findings of posterior acoustic enhancement
hyperechoic back wall
increased through transmission
What is the cause of dilated terminal ductal lobular unit
fibrocystic change
Is a dilated TDLU benign
yes
Describe a dilated TDLU
cluster of 2-3 mm cyst with thin intervening septations

no discrete solid part
What is a cluster of microcyst most likely gonna be
dilated TDLU (benign)
What are 2 examples of skin cyst
sebaceous or epidermal inclusion cyst
Where are both sebaceous and epidermal inclusion cyst located
dermis or subdermal
Describe a sebaceous cyst
hypoechoic
gland neck
Describe a epidermal inclusion cyst
heterogeneous
concentric echogenic layers
Can a hair follicle be seen sometimes with a sebaceous cyst
yes
Is there color flow in sebaceous and epidermal inclusion cyst
no
Where is the doppler flow in a LN
hilar region
What are some lesions that are complicated cyst
Fibrocystic change
galactoceles
lipid cyst
What are the findings of complicated cyst
internal echoes
ring down artifact
Do complicated cyst sometimes have uniform thick walled cyst, fluid fluid leveles,
yes
Can a complex cyst have circumferential wall calcifications
yes
What type of lesion typically has circumferential wall calcifications
oil cyst
What is a complex mass
cystic lesion with some solid components
eccentric wall thickening
mural nodules
thick septations
fibrovascular stalk
What type of neoplasms are complex masses most of the time
papillary neoplasm
Do complex cyst all get biopsied
yes
Can high grade invasive ductal cancer , medullary and lymphoma be very hypoechoic
yes
What are techniques to determine if something is solid or cystic besides doppler
compress
change pt position and levels or echogenic material will change position
If something is a simple cyst or a skin cyst what is the birads classification
2
If soemtheing is a complicated cyst or has clustered microcyst what is the birads classification
2 or 3
If something is a complex mass what is the birads level
4
If you are sampling percutaneously what must be left
clip marker (otherwise must undergo excision)
What do must radiologist call clustered microcyst
birads 3
If you are unable to determine if something is solid or not what is the classification
birads 3 or 4 (based on other features)
What is the appearance of solid masses to fat
hyperechoic to fat
What is the MC shape of a solid mass
ellipsoid shape
What are benign US features of a solid mass
hyperechoic
ellipsoid
3 or fewer gentle lobulations
thin echogenic pseudocapsule
abscence of any malignant feature
Is being ellipsoid and hyperechoic both benign characteristics of a solid on US
yes
Is having 3 or fewer lobulations or a thin ehcogenic pseudocapsule a benign characterisitc
yes
If a solid mass is hetergenous and 'ugly looking' and has hyperechoic components is it benign
yes
What are the malignant features of ultrasound
10
spiculations
taller than wide
angular margin
shadowing
branch pattern
markedly hypoechoic
calcifications
duct extension
microlobulations
disruption of tissue plane
Are spiculations and being taller than wide malignant features on US
yes
Are angular margins and shadowing malignant features on US
yes
What is taller than wide called on US
non-parallel
Are branching and being markedly hypoechoic malignant features on US
yes
What malignant features have highest PPV for predicting malignancy
spiculation
taller than wide (non-parallel
Again what are the benign characteristics of margins on US
circumscribed margins
oval or round
midly lobulated
What are malignant features of margins are
spiculated
microlobulated margins
irregular
What is the most important thing to consider when determing if a solid mass appears malignant
the margins
What did studies show that would happen to the NPV of predicting tumors if US was added
the NPV increases (can safely follow it)
When is it safe to follow birads 3
if it is mammographically and sonographically benign appearing
Can you call a new mass a birads 3
no (should be biopsied)
What happens if you birads something 3 by mammography and cant see it on US
-you know its not a cyst (bc you would see it)
-if it is well circumscribed, not new or growing, no suspicious features then can still call it birads 3
-if new or any suspicious features than birads 4 or 5
Are asymmetries seen on mammography ever evaluated by US
yes
What are 5 mammographic findings that can be analyzed by US
asymmetry
focal asymmetry
architectural distortion
calcifications
dilated ducts
Why do you analyze questionable mammographic features
3
determine if there is an US correlate
determine if it has benign or malignant features on US
determine if it is amenable to US guided procedure
What is a scenario of an asymmetry that might require evaluation by US
asymmetry is seen in one view but not the other
roll views doesnt eliminate it

then go to US
Is architectual distortion analyzed using US
yes
Why would you US a highly suspicious pattern of calcification such as fine pleomorphic
not for diagnosis, but only to see if it is amenable to US guided biopsy (no compression is necessary)
When you do a core biopsy of area of suspicous calcs what should be done to the samples to assure you have an adequate sample
x ray
Would you ever US segmental distribution of linear branching calcifications
yes, these are a 5 but it is helpful if these can be biopsied via US
Is there any diagnostic value to US malignant appearing calcifications
yes, actually studies show if microcalcifications are seen on US they are 3 x more likely to be malignant (doesnt usually change managment since you would have biopsied anyways)
What are some clinical symptoms that suggest malignancy
palpable lump, ridge, skin thickening, focal non-cyclical pain, nipple discharge (clear or blood..especially from one side)
What if there are SS to suggest malignancy but the mammogram is normal
consider US
What is a suspicious clinical presentation that always warrants US if mammogram is negative
nipple discharge
Why is it a good idea to US a palpable ridge if there is no explaination on mammo
bc this may be a palpable mass or a benign palpable ridge (but the patient will get an explaination)
What are 3 detectable causes of nipple discharge by US
duct ectasia
intraducatal mass
abscess
Can a large abscess be confused with a agressive carcinoma
yes (may look heterogenous and partly solid)
What percent of women will have malignancy and present with a palpable lump but have negative US and mammogram
4% (therefore alway aspirate if suspicious)
Do saline and silocone implants look the same on US
yes (when they are intact)
What is the appearance of breast implants when they are intact
hypoechoic
How many echogenic lines do a single and double lumen breast implants have
single 3 echogenic lines

double 5 echogenic lines
What is the MC reason to evaluate breast implants
palpable lesion
What is the MC reasons for a palpable lesion of a breast implant
3
radial fold
herniation
valve
What is the MC presentation of a contracture of the breast
one breast is larger than the other
What is the appearance of a saline implant rupture
the echogenic lines of the breast implant will be folded in on eachother
What is the US findings of an extracapsular silicone rupture
snow storm (outside of the implant)
What is the US findings of an intracapsular silicone rupture
stepladder sign
When is second look US utilized
a suspicious lesion is seen on MRI that wasnt initialy seen on US or mammo. Second look is utilized sometimes to reevaluate
Why is a second look US done after a lesion seen on MR is already deemed suspicious
bc you want to see if it is amenable to US guided bx
If a pt has mets that are suspcious for breast cancer and Mamo is negative is US utilized
yes
Is US used for evaluating response to therapy
yes
If a pt has birads 4,5 and 6 disease by mammo is US still done?
why?3
yes,
-evaluate for multifocal and multicentric disease
-evalutate for ipsilateral axilla and LAD
-assist in tx planning
What does a malignant LN look like
3
cortical thickening (asymmetric)
abnormal node adjacent to normal
increased peripheral flow
If there is increased flow in the cortex of the LN is that suspicous
yes, warrants a biopsy
When is whole breast ultrasound screening most useful
dense breast
What is the benefit and shortfall of US screening
increased detection of small cancer

increased biopsy (1 in 10) are cancer