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Hello and welcome to Noon Conference hosted by MRI Online. Noon Conference

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was created when the pandemic hit as a way to connect the global

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radiology community through free live educational conferences that are accessible

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for all. It has become an amazing weekly opportunity to learn alongside

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Online account. The link will be provided in the chat box.

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You can also sign up for a free trial of MRI Online premium

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membership to get access to hundreds of case based micro learning courses

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across all key radiology subspecialties. Learn more at mrionline.com. Today

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we're honored to welcome Dr. Jocelyn Rapelyea for a lecture on a practical

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guide to diagnostic breast ultrasound. Dr. Rapelyea is the Residency Program

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Director of Radiology and the Associate Director of Breast Imaging at the

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Medical Faculty Associates of George Washington University. She has lectured

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nationally and internationally and as a fellow in the society of breast

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imaging. She has taught many courses on the basics of breast ultrasound

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and new screening techniques with 3D breast ultrasound. At the end of the

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lecture, please join us in a Q&A session where she will address any

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questions you may have on today's topic. Please use the Q&A feature to

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submit your question and we will get to as many as we can

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before our time is up. With that being said, we are ready to

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begin today's lecture. Dr. Rapelyea, please take it from here.

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Yes, thank you for having me. So, today I will be speaking to

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you about diagnostic breast ultrasound. We do realize that ultrasound, particularly

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in the last decade has gained waves towards screening as well.

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But we will be speaking about diagnostic today.

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So, the one thing that I want to just state is that understanding

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ultrasound really has to come from understanding the breast anatomy as well.

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That way we can really kind of apply the features for our analysis

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of any type of abnormality that we see, and we can determine the

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final assessment code which will then define the management of that patient.

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If we look at anatomy overall, there are really four basic things that

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we look at, and that is skin, the lobules or the segments of

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the lobes, the TDLU which is where we have the cancerous cells that

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can potentially develop, but we also have a lot of benign things that

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develop in the TDLU as well. And then of course, the chest musculature

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is something that we look at when there's a potential for recurrence where

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if there is an adjacent cancer that potentially could be invading into that

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area. I will tell you that the fibroglandular zone, which is something that

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we will be looking at distinctly on the ultrasound

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really is made up mostly of the lobes or the segments of the

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breast tissue, the glandular tissue, and the TDLU. But, all in all,

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the basic elements of breast anatomy which would be the ducts, the lobules,

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the fibrous connective tissue as well as the fat are things that we

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can know on the ultrasound. So if we look at starting off at

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the skin surface, we realize that the skin can be affected by things

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that are benign as well as things that are cancerous. We look at

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the size of it and the size in itself is usually about 2

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millimeters, so it's very thin, it's usually by a hyperechoic line, followed

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by hypo and then another hyperechoic line. And why does that matter?

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Well, because things that are potentially arising in the skin can develop

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and we are not sure whether it's actually in the skin or the

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underlying breast parenchyma, so within that subcutaneous fat. And we look

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at the thickness which can actually help us particularly if patient winds

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up having prior surgery where there's surgical scar. So if we see some

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type of distortion and the thickening over top and it extends to the

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surface of the skin, we know that's most likely benign.

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However, we do have inflammatory processes such as infectious processes

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or underlying cancerous... Inflammatory cancer that can develop within the

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breast. And so we look at these things, particularly if you look on

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the right of the screen you can see that there are these dark

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channels that are within the hyperechoic portion of the subcutaneous fat.

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And that's really just engorgement, I should say, of the lymphatic channels

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that are there, which is worrisome if a patient does not have clinical

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history of having a fever or any other type of

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process such as lactation that would preempt them from having a mastitis.

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But if they're in their perimenopausal years or even postmenopausal, we

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would think about inflammatory breast cancer. More common than that though

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I would say that you know just looking at the skin surface,

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we usually wind up seeing epidermal inclusion cysts. It can be difficult

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to see these sometimes within the skin, per se. We look to see

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again for that hyperechoic line, followed by the hypo, and then hyper again.

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But if we don't see that punctum going all the way up to

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the surface, it can be difficult. And the way to be able to

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appreciate that is what you see here is where we have a thicker

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layer of gel that's over top of it so that we could potentially

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give ourselves some chance of being able to see that punctum. If we

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see that then we're very happy and we can move on and just

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have clinical follow up for that patient. But if we don't,

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it can be a little worrisome if the patient's complaining of a new

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palpable lump. Also, if they wind up with their history of having high

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risk. So what we do is looking at

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the skin surface, there's also underlying it, if you can see,

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in this case I have an arrow where there is a hyperechoic mass that

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is extending into the epidermal layer. The skin is somewhat thickened over

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top so it's way more than that 2 millimeters that we were discussing

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before. And you can see that the hyperechoic, hypoechoic and hyperechoic

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line really dives down towards this mass that you can see by that

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green arrow. And this was a patient that wind up having a

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cancer close towards the nipple that was tugging on the nipple and starting

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to cause a little bit of retraction. We can also see,

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involving the skin and directly underlying where the nipple is in the periareolar

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region, sometimes the milk ducts and their normal milk ducts usually have

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the same caliber if you go all the way across the

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screen on the ultrasound. But in this case, you can see that there

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is marked by arrows, hypoechoic.