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Ultrasound and Mammogram What Should You Know 1

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Ultrasound and Mammogram What Should You Know 1 Ultrasound and Mammogram what should you know 1 Ultrasound and Mammogram what should you know จัดท ำโดย พญ.ภัคพิชำ ควรค ำนวน อำจำรย์ที่ปรึกษำ อ.นพ.ก ำพล รัชวรพงศ์ Normal anatomy 1 เต้ำนมของผู้หญิงที่มีกำรเจริญเติบโตเต็มที่แล้ว มีลักษณะแตกต่ำงกันมำก เป็นผลมำจำกปัจจัยต่ำงๆทั้งภำยในและ ภำยนอกร่ำงกำย โดยเฉพำะอิทธิพลของฮอร์โมนเพศ และพันธุกรรม โดยทั่วไปเต้ำนมในหญิงที่ยังไม่ผ่ำนกำรตั้งครรภ์จะมีลักษณะ เป็นรูปโดมครึ่งวงกลม วำงอยู่บนผนังทรวงอกด้ำนหน้ำ บริเวณ intercostal space ที่ 2-6 ในแนวตั้ง และบริเวณขอบนอกของ กระดูก sternum จนถึงบริเวณ anterior หรือ mid axillary line ในแนวนอน โดยวำงอยู่บนกล้ำมเนื้อ Pectoralis major, Serratus anterior, External abdominal oblique, รวมถึงส่วนบนของ rectus sheath โดยมี potential space อยู่ระหว่ำง เต้ำนมและกล้ำมเนื้อของผนังทรวงอก เรียกว่ำ Retromammary space บำงครั้ง อำจมีเนื้อเยื่อเต้ำนมแผ่ขยำยไปจนถึงบริเวณใต้ รักแร้ เรียกส่วนนี้ว่ำ Axilllary tail (of Spence) เต้ำนมประกอบด้วยโครงสร้ำง 3 ประเภท ได้แก่ 1. ผิวหนังที่ปกคลุมบริเวณเต้ำนม มีลักษณะบำง พบต่อมไขมัน ต่อมเหงื่อ และรูขุมขนได้ บริเวณสูงสุดของเต้ำนมจะมีหัวนม ซึ่งเป็นที่รวมรูเปิดท่อน้ ำนม หัวนมจะ ล้อมด้วยลำนนม ซึ่งมีเส้นผ่ำนศูนย์กลำงประมำณ 15-60 มิลลิเมตร 2. เนื้อเยื่อไขมันใต้ผิวหนัง แบ่งเป็น 2 ชั้นคือ superficial pectoral fascia และ deep pectoral fascia โดยเนื้อเยื่อเต้ำนมจะแทรกอยู่ระหว่ำงชั้น ไขมันทั้งสองชั้นนี้ นอกจำกนี้ยังพบเส้นใยของเนื้อเยื่อเกี่ยวพันที่ยึดระหว่ำงผนังทรวงอกกับผิวหนังที่ปกคลุมเต้ำนม เรียกว่ำ suspensory ligament (of Cooper) โดยเส้นใยเหล่ำนี้จะแทรกผ่ำนไปในชั้นไขมันและเนื้อเต้ำรม เพื่อท ำหน้ำที่ช่วยในกำรคงรูป ของเต้ำนม 3. เนื้อเต้ำนม (breast tissue) Ultrasound and Mammogram what should you know 2 ในส่วนนี้ประกอบด้วย parenchyma และ stroma เต้ำนมประกอบด้วย 7-8 lobes หรืออำจจะมำกถึง 20 lobes อยู่กันอย่ำงหลวมๆ สัมพันธ์กับท่อน้ ำนม แต่ละส่วนจะ ประกอบด้วย เริ่มที่ fine peripheral branches และสิ้นสุดที่ large collecting duct Ultrasound and Mammogram what should you know 3 Ultrasound Normal breast ultrasound imaging 2 Skin Subcutaneous fat Fibroglandular tissue Retromammary fat Pectoralis muscle (Breast imaging) A and B, Normal breast ultrasound scan in fatty, mixed and dense breasts Nipple and areola หัวนมปกติ จะมีลักษณะ prominent, flat, inverted Ultrasound and Mammogram what should you know 4 A and B: enables the skin and superficial tissue to be seen. The nipple is normal ระบบน้ ำเหลืองของเต้ำนม (Lymphatic drainage of the breast) 3 เริ่มขึ้นจำกท่อน้ ำเหลืองที่อยู่รอบท่อน้ ำนม และเต้ำนม และระบำยน้ ำเหลืองออกจำกเต้ำนมโดยผ่ำนทำงเดินน้ ำเหลืองที่มี กำรเชื่อมต่อกัน ส่วนใหญ่จะรวมกันเป็นเส้นทำงหลัก 1-2 เส้น และระบำยสู่ต่อมน้ ำเหลืองที่รักแร้ (axillary lymph node) ใน กลุ่มเดียวกัน หรือใกล้เคียงกัน นอกจำกนี้ท่อน้ ำเหลืองจำกด้ำนในของเต้ำนม ยังสำมำรถเชื่อต่อกับท่อน้ ำเหลืองทำงด้ำนตรงข้ำมได้ โดยผ่ำนระบบน้ ำเหลือง internal mammary ที่วำงอยู่ตำมหลอดเลือด internal mammary อีกด้วย ในทำงพยำธิกำยวิภำคศำสตร์ อำจแบ่งต่อมน้ ำเหลืองบริเวณรักแร้ออกเป็น 3 level โดยใช้เส้นสมมติที่อ้ำงอิงจำก กล้ำมเนื้อ Pectoralis minor ได้แก่ Level 1 อยู่ lateral ต่อกล้ำมเนื้อ ประกอบด้วยต่อมน้ ำเหลืองกลุ่ม anterior, lateral และ posterior Level 2 อยู่ใต้ต่อกล้ำมเนื้อ ประกอบด้วยต่อมน้ ำเหลืองกลุ่ม central Level 3 อยู่ medial ต่อกล้ำมเนื้อ ประกอบด้วยต่อมน้ ำเหลืองกลุ่ม apical หรือ subclavicular น้ ำเหลืองจำกเต้ำนมส่วนใหญ่จะระบำยเข้ำสู่ต่อน้ ำเหลืองใน level 1 ก่อน จำกนั้นจึงระบำยเข้ำสู่ level ถัดไป แต่บำงครั้งพบว่ำ น้ ำเหลืองจำกเต้ำนมสำมำรถระบำยสู่ต่อมน้ ำเหลือง level 2 และ 3 ได้โดยตรง เรียกว่ำ skip metastasis Ultrasound and Mammogram what should you know 5 แสดงต่อมน้ ำเหลืองกลุ่มต่ำงๆของ axilla ซึ่งส่วนใหญ่จะวำงอยู่ตำมหลอดเลือด axillary vein และแขนง แสดงกำรแบ่ง level ของ axilla เป็น 3 level โดยอ้ำงอิงจำกกล้ำมเนื้อ Pectoralis minor (G) และ (H) normal lymph node คือมีลักษณะเป็น lobulated hypoechoic mass with an echogenic center (fatty hilum) Ultrasound and Mammogram what should you know 6 (I) และ (J) Cooper ligaments และ normal fatty tissue (K) และ (L) Landscape ultrasound แสดงลักษณะ echogenic skin line, dark subcutaneous fat, dense glandular tissue สีขำว, และ pectoralis muscle ที่วำงอยู่บน chest wall ที่มีกระดูกซี่โครงวำงสลับกับ intercostal muscle โดยกระดูกซี่โครงจะเห็น acoustic shadowing Normal axilla ultrasound imaging Lymph Node ปกติจะมีรูปร่ำงคล้ำยไตหรือเมล็ดถั่วด ำ (reniform shape) ตรงกลำงมีไขมันอยู่ (central fat) Lymph node ลักษณะของ Suspicious Lymph Node - มีขนำด ≥ 1 เซนติเมตร - รูปร่ำงกลมผิดปกติ (abnormal round shape) - Abnormal hypoechoic cortex - Cortical thickening (eccentric cortical thickening) - Increased blood flow (non-hilar vessels) - Abnormal high resistance flow - Complete obliteration of fat hilum Ultrasound and Mammogram what should you know 7 Labeling and measurement 4 • Labeling 1. Facility name and location 2. วันที่ท ำกำรตรวจ 3. ระบุชื่อ-สกุล อำยุของผู้ป่วย 4. เลขที่โรงพยำบำล และ/หรือ วันเดือนปีเกิด 5. ระบุว่ำเป็นเต้ำนมข้ำงซ้ำยหรือขวำ 6. Anatomic location โดยใช้เป็นบอกเป็นเวลำตำมหน้ำปัดนำฬิกำ หรือระบุใน diagram ของเต้ำนม 7. Transducer orientation (เช่น radial, antiradial, oblique, transverse, sagittal) 8. ระยะห่ำงจำกหัวนม 9. ผู้ตรวจ และ/หรือ เลขวิชำชีพใบอนุญำตประกอบวิชำชีพเวชกรรม 10. อธิบำยสัญลักษณ์ต่ำงๆ • Measurement: กำรวัดขนำด วัดเป็น 3 มิติ โดยหน่วยเป็น มิลลิเมตร หรือ เซนติเมตร 1. Longest axis ของ lesion 2. ตั้งฉำกกับ long axis 3. บิด probe 90⁰ จำกรูปแรก ภำพแสดงกำรวัดขนำดของก้อน Ultrasound and Mammogram what should you know 8 Breast ultrasound lexicon 5 Ultrasound Lexicon Breast A. homogeneous - fat composition B. homogeneous - fibroglandular C. heterogeneous Mass shape oval – round - irregular margin circumscribed or not circumscribed: indistinct, angular, microlobulated, spiculated orientation parallel – not parallel echo pattern anechoic – hyperechoic – complex cystic/solid, hypoechoic – isoechoic - heterogeneous Posterior no features – enhancement – shadowing – combined pattern features Calcifcations In mass – outside mass - intraductal Associated architectural distortion – duct changes – skin thickening – skin retraction – edema – features vascularity (absent, internal, rim) - elasticity Special cases simple cyst – clustered microcysts – complicated cysts – mass in or on skin – foreign (cases with a body (including implants) – intramammary lymph nodes – AVM – Mondor disease – unique postsurgical fluid collection – fat necrosis diagnosis) A. Breast composition Homogeneous - Fat: uniform hypoechoic fat lobules with echogenic Cooper’s ligament เห็นเป็นสีเทำ - Fibroglandular: homogeneous echogenic fibroglandular parenchyma เห็นเป็นสีขำว HOMOGENEOUS BACKGROUND EVHOTEXTURE – FIBROGLANDULAR (F) Ultrasound and Mammogram what should you know 9 Heterogeneous - ลด sensivity - สำมำรถพบได้ในเต้ำนมหญิงสำวอำยุน้อย HOMOGENEOUS BACKGROUND ECHOTEXTURE – an admixture of fat and fibroglandular tissue B. Masses ลักษณะของก้อน คือ จะเห็นได้ทุกระนำบ(3-D) โดยในกำรตรวจ ultrasound ก้อนจะเห็น 2 ระนำบ(2-D) Pseudo mass - Fat lobule: echogenicity เท่ำกับ fat จะเห็น lesion อยู่ในชั้น subcutaneous - Ribs: กระดูกซี่โครง Fat lobule Ribs Ultrasound and Mammogram what should you know 10 1. Shape: Oval, Round, Irregular Round Oval Irregular 2. Margin - Circumscribed: ขอบเขตเรียบชัด Circumscribed Not circumscribed - Not circumscribed: ขอบเขตไม่ชัดเจน Indistinct (included echogenic rim): ขอบไม่ชัด Angular: มุมแหลม Microlobulated: เป็นลอนขนำดเล็กๆ Spiculated: เป็นแฉกๆ Indistinct Angular Microlobulated Spiculated Ultrasound and Mammogram what should you know 11 3. Oreintation: อ้ำงอิงจำก skin line - Parallel: วำงตัวในแนวนอน โดยแกนยำวของ lesion ขนำนไปกับ skin line lesionแบบนี้มักจะเป็น benign - Not parallel: วำงตัวในแนวตั้ง ลักษณะ lesion เป็น taller than wide lesionแบบนี้มักจะเป็น malignant เนื่องจำกก้อนเนื้อมักจะเจริญเติบโตตั้งฉำกกับผิวหนัง Parallel Not parallel 4. Echo pattern: ที่เห็นเป็นสีขำวหรือสีด ำ โดยใช้ mammary fat เป็นตัวเปรียบเทียบ - Anechoic: สีด ำสนิท - Hyperechoic: สีขำวกว่ำเนื้อเยื่อไขมัน - Complex cystic and solid: มีทั้งสีด ำสนิทของส่วนที่เป็นน้ ำและมีส่วนที่เป็นเนื้อด้วย - Hypoechoic: สีด ำกว่ำเนื้อเยื่อไขมัน - Isoechoic: สีใกล้เคียงกับเนื้อเยื่อไขมัน - Heterogeneous Anechoic Hyperechoic Complex cystic and solid Hypoechoic Ultrasound and Mammogram what should you know 12 Isoechoic Heterogeneous 5. Posterior features: ลักษณะคลื่นเสียง ultrasound ที่ผ่ำนก้อนนั้น A. No posterior feature: พบลักษณะหลังก้อนปกติ B. Enhancement: พบลักษณะสีขำวขึ้นหลังก้อน มักพบใน cyst, solid tumor โดยเฉพำะกรณีมี high grade invasion C. Shadow: พบลักษณะมีเงำสีด ำหลังก้อน มักพบใน fibrosis, scar, desmoplastic จำก tumor D. Combined pattern: มีลักษณะหลำยประเภทปนกัน พบลักษณะนี้ใน lesion ที่มี fibrosis No posterior feature Enhancement Shadow Combined pattern C. Calcifications - Calcifications in mass - Calcifications outside mass - Intraductal calcifications Ultrasound and Mammogram what should you know 13 Calcifications in mass (calcified fibroadenoma) Calcifications outside mass (Calcifications are seen with the fibroglandular tissue) Intraductal calcufications (The extensive intraductal component of this invasive ductal carcinoma is manifested by the several calcification (arrow)) Ultrasound and Mammogram what should you know 14 D. Associated features (surrounding tissue) - Architectural distortion Manifestation of Architectural distortion is that Cooper ligaments are straight (arrows) versus their normal arc shape - Duct changes ปกติท่อน้ ำนมจะ smooth, regular ขนำดท่อน้ ำนมจะเล็กลงเรื่อยๆจำกที่ฐำนของหัวนมไปจนถึงเนื้อเต้ำนม กำรมี ลักษณะท่อน้ ำนมที่ผิดปกติไป อำจมีสำเหตุมำจำกมะเร็งในท่อน้ ำนม, intraductal mass หรือ thrombus Duct change Ultrasound and Mammogram what should you know 15 - Skin thickening ผิวหนังหนำขึ้นจำกควำมหนำปกติ มำกกว่ำ 2 มิลลิเมตร อย่ำงไรก็ตำมบริเวณ periareolar และ inframammary fold
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