Methods of ultrasound of the mammary glands

To assess the localization of pathological processes, the mammary gland is divided into:

• nasoskovy, sucking segments and okolososovuyu area;
• four quadrants (upper outer, lower outer, lower inner, upper inner), and okolososkovuyu area;
• sectors by analogy with the numbers on the dial (09:00, 12:00, etc.).

Getting to master the ultrasound of the mammary glands, from the very beginning it is necessary to take as a rule the same sequence of examination of the mammary glands. The echography is performed in the position of the patient lying on the back, with a convenient location of the head, arms lowered along the trunk. The investigation of the right gland begins with the upper outer quadrant, then examines in turn the lower outer, the lower inner and ends with the upper inner quadrant. The left mammary gland is examined starting from the upper inner quadrant in a counter-clockwise direction, completing the examination in the upper outer quadrant. Observance of a certain sequence of movement of the sensor makes it possible to avoid any further divisions of the mammary glands in the future. Inspection of the mammary glands is carried out by moving the sensor from the external sections of the gland to the nipple or in the opposite direction. This movement of the sensor corresponds to the anatomical location of the glandular lobes and milky ducts. The nipple and the nasal region are examined using a large amount of gel, either with a silicone gasket or water nozzles. The sensor is moved along the main axis of the milk ducts from the nipple to the periphery of the organ. For a better visualization of the toe region, additional compression is performed by the sensor and not only standard straight lines but also slanting slices are used. Complete the examination of the mammary glands by analyzing the state of the regional lymphatic drainage zones.

To standardize the examination of patients with pathological changes in the mammary glands, according to the scheme proposed by Pickren, the ultrasound landmarks of the three zones are identified for the search of pathologically altered lymph nodes. Axillary zone - from the lateral border of the small pectoral muscle to the lateral margin of the axillary region. Its guideline is the axillary vein and the external thoracic artery. The subclavian zone is from the lower edge of the clavicle to the medial border of the small pectoral muscle. Its guideline is the subclavian artery. The supraclavicular zone is from the upper edge of the clavicle to the medial margin of the digastric muscle. Its orientation is the thoracoacromial vein. We completed this scheme by examining the antero-thoracic zone from the lower edge of the clavicle along the mid-clavicular line (along the small pectoralis muscle) to the border with the mammary gland. This concludes the review (screening) stage in the examination of the mammary glands, in which:

1. the state, quantity and nature of distribution of stroma, glandular structures, milk ducts and fatty tissue;
2. clarity of differentiation of the tissues of the mammary glands (with the indication, if necessary, of the cause of their poor detail);
3. violations of the architectonics of the mammary glands with their attribution to the group of diffuse or focal (their location and dimensions are described).

All changes found in one mammary gland are compared with symmetrical sites in the contralateral mammary gland. In conclusion, the status of regional lymphatic drainage zones is necessarily assessed.

At the stage of ultrasound mammography, the sensor is returned to the zone of atypical tissue structure. This determines the state of the contours, visualization of the front and rear walls, the presence of additional acoustic effects. The internal echostructure of changes and the condition of adjacent tissues are necessarily assessed. Evaluation of images of tissues is made not only in the usual mode, but also with additional compression of breast tissue (in the "compression" mode). When the sensor pressure is applied to the gel-lubricated skin, the thickness of the tissues between the sensor and the zone of interest decreases, due to the compaction of the structures, the visualization of deeply located formations improves, the severity of the side shadows-artifacts from the gland's own tissues decreases. In addition, the compression mode allows you to obtain additional information about the change in the form of education, internal structure, the relationship with surrounding tissues.

The internal structure of benign formations becomes more uniform under compression, the shape changes more often (flattened), the contours are visualized more clearly. Malignant formations are not characterized by a change in shape and internal architectonics during compression.

The shaking intake is used to determine the displaceability of internal contents. The formation fixed between the thumb and forefinger of the left hand is swung from side to side. The sensor is located above the formation, and the changes occurring in the formation are evaluated on the monitor screen.

At the same time, the dislocation of education with respect to surrounding and underlying tissues is evaluated to determine the nature of the growth of education (infiltrative or expansive).

When revealing pathological changes, their evaluation is carried out in two mutually perpendicular planes. This approach allows to measure three parameters (width, thickness and length) and correlate echographic findings with the results of X-ray mammography and morphological data.

With large sizes of mammary glands, the examination is carried out in the patient's position lying on his side, sitting, standing, with his hands raised behind the head.

To compare the echographic data with the data obtained in X-ray mammography (especially in women with large mammary glands), the study is conducted in the sitting position. In this case, the mammary gland is placed by its lower surface on the table (or raised by the hand of the patient). When tested in this position, the tissues are flattened between the sensor and the surface of the table, which imitates the standard cranio-caudal position for x-ray mammography. If a malignant process in the gland is suspected, it is necessary to assess the state of the target organs. Given the characteristics of lymphatic drainage of the breast, they include: liver, ovaries and inguinal lymph nodes. With some diseases, for example, with dyshormonal processes in the mammary gland, it is necessary to visualize and determine the functional state of the thyroid gland to find out their cause.

To improve the accuracy of ultrasound examination after evaluation of the mammary glands in the B-mode, it is advisable to use dopplerography of the mammary gland vessels with obtaining the Doppler spectrum, color Doppler mapping, energy Doppler.

Most often at present, the index of resistance (IR) and pulsation index (PI) are used to characterize benign and malignant changes in the mammary glands. According to Medl and Konishi, the resistance index is the most important. When assessing the resistance index, the sensitivity of duplex Doppler ultrasonography in detecting breast cancer is 84%, the specificity is 80%. According to Lee, the appearance of color Doppler mapping of signals from vessels (both inside and around the periphery of volumetric formation of the breast) is treated as a sign of malignancy.

[1], [2], [3], [4], [5], [6], [7]