The Basics of the Breast

Let's talk about boobs!

Breast ultrasound is an essential part of the breast cancer screening process, and there's a lot to it. I'll try to pinpoint what I found to be the most helpful and important tips I gained along the way while I worked in a breast cancer center, and from breast scanning in the hospital setting since then.

Many women (and men) come in for breast imaging because they feel lumps in their self-exams. It's important to consider all factors when identifying a patient's risk for breast cancer. So, let's get personal.

Here are some things worth chatting to your patient about:

Personal history of breast findings, biopsies, cancer treatments, etc.

Family history of breast cancer or ovarian cancer, age of diagnosis, and how they are related to the patient

Have they lost or gained a good amount of weight recently? (Weight gain can be a risk factor. Weight loss can be a clue for you. Lumps felt by patients can actually be pre-existing normal lumpy tissue, but if they lost weight recently, those lumps seem to stand out more from the crowd now)

Do they take hormones, including birth control?

Here are some things that are probably not as easy to work casually into conversation, but still worth noting in the patient's history:

Ashkenazi Jewish heritage

BRCA gene testing

Age of first period (younger=higher risk), age of first pregnancy (if any; older=higher risk)

One piece of valuable information that I took from the breast center radiologists and often passed on to patients:

Diffuse breast pain is not a common symptom of breast cancer.

Now. That said, of course tumors can be painful. No one wants to downplay a patient's concern. The point here is that there are so many reasons for breast pain; if the entire breast is sore, it's not likely that it's due to breast cancer. There are many other things to consider first. Hormones, weight loss, and weight gain can all affect these things. If breast pain is a problem, suggest Vitamin E, sleeping in a sports bra, switching from underwire bras, or maybe even applying light heat to relax muscles.

"Just tell me how to scan already!"

I know I get it, but I also know that these non-sonographic tidbits came in handy for me when patients had questions relating to their situation, and are also good to know about for yours and my own boob health. Now let's get hands-on.

While prepping for the patient, look at any prior mammograms and breast ultrasounds. If there was a mammo done immediately prior, and you are to correlate a finding, make sure you see what they found on the mammo and know the area in question. Learning to read a mammogram will do wonders for your scan prep.

When scanning the breast, use a high frequency linear probe. It's important to first do an intentional and thorough search through the area, because breast tissue can be very difficult to look at. Gel up the area in question and scan through before taking images. Scan through on high frequency, looking through the superficial layers. Lower the frequency and look through the deeper layers if the breast is larger. Get yourself comfortable with the individual's tissue before committing to images. The more comfortable you feel with what you're looking at, the easier your job will be.

When labeling images, a common way to indicate lesion location is the following:

Radial/anti-radial (or sagittal/transverse, depending on your center's preference)

Clock position

Centimeters from nipple

For instance:

http://www.metritrack.com/the-challenge-of-dense-breasts

EDIT: I meant to say this originally, but it fell out of my brain. Some places may also use a ABC 123 way of identifying location. ABC indicates depth, with A being superficial and C being deep. 123 indicates distance from nipple, with 1 being closest to nipple and 3 being on the periphery. For instance, an annotation of 2B would indicate the lesion being midway in depth and midway between the nipple and the periphery.

When correlating with mammo, it's helpful to work in quadrants. Narrow down in which quadrant you're seeing the finding on mammography, and search there.

Document any obvious lesions, measuring and applying color when necessary.

As well as the obvious shaped lesions, look out for inconsistencies in the tissue, such as architectural distortions and shadowing, or ductal dilatation.

Vocal fremitus is another helpful technique. When looking at a lesion in question, document. Then, apply power Doppler and have the patient hum. Normal breast tissue will light up with the vibration, while abnormal lesions will not; thus giving you a better idea of the shape and contour of a lesion. See below for example images from a wonderful article I found:

When scanning breasts, it's always important to look at the retroareolar area for ductal discrepancies, as well as through the axilla and tail of Spence for any reactive lymph nodes- especially with tumor findings. Become familiar with the BI-RADS categories so that you can be one step ahead of the radiologist with helpful imaging they might require to decide next steps for the patient, such as biopsy.

If you are unable to locate a mammographic finding with ultrasound, try not to get frustrated! Some things are seen more easily on mammo, and that's also good to know. That way they will know to schedule the patient for a stereotactic biopsy instead of ultrasound guided, if that's what's necessary.

The one note I will leave you with is this:

Be kind.

Be kind to your patient, especially in this setting, even if you think they are being dramatic or pushy. They might be very scared, especially if they don't know much about what's happening. Lay some of your newfound knowledge on them and help ease their worries. Don't give false hope, but be there to listen and offer information as best you can. Don't make things up. If you don't have an answer, have resources available to offer.

Let me know if there's anything you want elaborated on in another post!

Be good to your boobies!

Jordyn