HOW+TO+SCAN+A+BREAST

**﻿ How To Scan A Breast**

 * Along with new techniques for ultrasound scanning, new institutions and organizations have arisen to help women obtain the highest quality breast ultrasound scans. The ARDMS Registry in Breast Ultrasound will emphasize modern scan techniques and identify individuals qualified to perform breast ultrasound. The AIUM breast ultrasound accreditation program helps ensure that breast imaging centers not affiliated with general imaging centers are performing high- quality breast ultrasound. Further work remains to be done on training centers for moving new technologies into clinical practice

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 * **Set Up and Positioning**
 * Adequate breast examinations can be performed with either high-frequency automated whole-breast ultrasound units or hand-held instruments with a transducer operating at 5 MHz or greater frequency, and with a depth of focus of no more than 3 cm.
 * Patients usually scanned in the supine position
 * Ipsilateral arm is raised above the head -- provides a more stable scanning surface
 * For the lateral margin of the breast -- patient can be rolled slightly toward the opposite side
 * For the medial portion of the breast -- supine position works well
 * If a lesion identified on mammo cannot be located with U/S, sitting the patient upright in the same position as the mammo may be helpful
 * Optimize the image quality with focusing, TGC, and overall gain.
 * Goal is to balance the image from the low-level echoes of the subcutaneous fat to the low level echoes of the retromammary fat
 * Moderate compression should be applied when scanning
 * In the case of a normal breast the usual protocol requires the following
 * Images of each quadrant
 * The subareolar ducts
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Specific radial images of the breast -- depending on your sites protocol



<span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">**Scanning Technique**
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">When a patient is being evaluated for a palpable breast mass or for a specific abnormality seen on mammogram, a preliminary scan is done first to locate the abnormality.
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Helpful to mark the external skin over the mass
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Transducer orientation should remain the same as with conventional U/S
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Evaluate all lesions in two planes
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Can be recorded with sagittal and transverse images or radial/anitradial transducer positions
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Radial/Antiradial positions are unique to breast scanning
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Radial scanning is critical for the detection of intraluminal mammary duct lesions.
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Compression is important for characterization of solid masses
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Cancers compress much less than benign lesions.
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Solid masses may be isoechoic relative to the surrounding tissue especially when surrounded by fatty tissue, and looking for an area that does not compress as much as the adjacent tissue will help to detect the lesion.
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Palpation during scanning allows for precisely localizing palpable abnormalities relative to the ultrasound image.
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Palpation enables the examiner not only to find subtle lesions but also to determine when normal structures such as fat lobules and thickened Cooper's ligaments are causing a palpable abnormality.
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Radial and Antiradial Scanning
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">All solid lesions should be scanned in the plane of the ductal system (radial and antiradial)
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Demonstrates subtle projections that course toward the nipple or branch outward in the breast
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">If a nodule is scanned using only the conventional planes subtle findings may be missed
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Lesions may falsely appear spheroid or ellipsoid
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Lesions misclassified as probably benign
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Optimization
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Solid lesions may look cystic if gain is not properly set for breast scanning [[image:Image8.gif width="719" height="306" align="right"]]
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Before scanning area of intrest, find an area of fatty tissue
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">usually inner aspect of breast
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">set gain so fat is medium grey
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Compare all lesions in the breast with fat
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">If gain is set correctly glandular tissue and most benign lesions will appear isoechoic to mildly hypoechoic
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Malignant lesions can be mildly hypoechoic to markedly hypoechoic
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Cysts are markedly hypoechoic to anechoic
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Structures hyperechoic to the fat include
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Skin, fibrous tissue, and calcifications

<span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">**Annotation**


 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Labeling is extremely important in the identification and correlation of breast images from other modalities
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Quasigrid pattern is popular
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Views the breast as a clock face
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Directly above the nipple on either breast is 12 o'clock
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Right medial breast and left lateral breast are 3 o'clock
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Directly below nipple on either breast is 6 o'clock[[image:ar_breastultrasound_main_en.jpg align="right"]]
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Right lateral and left medial breast are 9 o'clock
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Many imaging centers will further subdivide the breast with three concentric circles
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">First ring - 1/3 of breast - encompassing area just outside nipple - Zone 1
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Second ring - 2/3 of breast surface from nipple - Zone 2
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Third ring - breast periphery - Zone 3
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Lesions located close to the nipple are labled "A", lesions in the middle of the breast are labeled "B", and outer margin is labled "C"
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Depth of any pathology is documented
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Breast divided into thirds from skin to pectoralis major
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Depth A is the most superficial third
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Depth B is the middle layer
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Depth C is the deepest third of the breast
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Superficial lesions are labeled as "1", middle lesions as "2", and deep lesions "3"
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Orientation of the mass is also important
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Determined by aligning the transducer with the longest axis of a lesion
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Identify whether its long axis is oriented in a radial or antiradial plane
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Malignancies tend to grow within the ducts and will often follow the ductal system in a radial plane towards the convergence at the nipple

<span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">**Lable Example -- RT BREAST 2:00 B3 RAD**
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">Lesion is in the right breast, deeply situated towards the chest wall in the 2 o'clock position midway between the nipple and the outer margin of the breast, its long axis is oriented radially towards the nipple.

**OTHER ANNOTATION EXAMPLES** <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 120%;">**﻿**

<span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 110%;">**Ultrasound Pitfalls**
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 110%;">Psuedomass
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 110%;">Infiltrative pattern
 * <span style="font-family: 'Palatino Linotype','Book Antiqua',Palatino,serif; font-size: 110%;">Large, fatty breast