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Case Series

Three-Dimensional Ultrasound
Imaging of Mammary Ducts in
Lactating Women
A Feasibility Study
Mark J. Gooding, MEng, DPhil, Joanna Finlay, BSc, PhD,
MSc, DipIPEM, Jacqueline A. Shipley, BA, MSc, PhD,
Michael Halliwell, BSc, PhD, Francis A. Duck, PhD, DSc
Objective. The main function of the breast is to produce milk for offspring. As such, the ductal system, which carries milk from the milk-secreting glands (alveoli) to the nipple, is central to the natural
function of the breast. The ductal system is also the region in which many malignancies originate and
spread. In this study, we aimed to assess the feasibility of manual mapping of ductal systems from 3dimensional (3D) ultrasound data and to evaluate the structures found with respect to conventional
understanding of breast anatomy and physiology. Methods. Three-dimensional ultrasound data of the
breast were acquired using a mechanical system, which captures data in a conical shape covering most
of the breast without excessive compression. Manual mapping of the ductal system was performed
using custom software for data from 4 lactating volunteers. Results. Observational results are presented for ultrasound data from the 4 lactating volunteers. For all volunteers, only a small number of
ductal structures were engorged with milk, suggesting that the lactiferous activity of the breast may
be localized. These enlarged ducts were predominantly found in the inferior lateral quadrant of each
breast. The observation was also made that the enlarged, milk-storing parts of the duct were spread
throughout the ductal system and not directly below the nipple as conventional anatomy suggests.
Conclusions. Ultrasound visualization of the 3D structure of milk-laden ducts in an uncompressed
breast has been shown. Using manual tracing, it was possible to track milk-laden ducts of diameters
less than 1 mm. Key words: ampulla; breast; lactation; mammary duct; 3-dimensional ultrasound.

Abbreviations
3D, 3-dimensional; 2D, 2-dimensional
Received June 15, 2009, from the Department of
Medical Physics and Bioengineering, Royal United
Hospital, Bath, England (M.J.G., J.F., J.A.S., F.A.D.); and
Department of Medical Physics and Bioengineering,
Bristol General Hospital, Bristol, England (M.H.).
Revision requested July 9, 2009. Revised manuscript
accepted for publication July 27, 2009.
We thank Dorothy Goddard, MBChB, MRCP,
DMRD, for providing use of the scanning facilities.
Dr Gooding was funded by the Research and
Development Committee of the Royal United
Hospital. Development of the 3-dimensional scanner
was supported by grant A126 from the New and
Emerging Applications of Technology Program of
the UK Department of Health.
Address correspondence to Mark J. Gooding,
MEng, DPhil, Nuffield Department of Obstetrics and
Gynecology, University of Oxford, Oxford OX3 9DU,
England.
E-mail: mark.gooding@obs-gyn.ox.ac.uk

Motivation to Study the Ductal/Lobular Systems

of the Breast
Most research into breast ultrasound analysis concerns
the detection and diagnosis of lesions; therefore, the
detection and display of mammary ducts may seem
somewhat peripheral in this regard. Because most malignancies originate in the epithelial tissues of the ducts,1,2
investigation of the ductal system is an important area for
study. It has been suggested that ductal echography, a
process whereby the breast volume is systematically
scanned by following the paths of the ducts, is the best
way to find and diagnose lesions.1 The ability to generate
a 3-dimensional (3D) map of the ductal structure of the
breast could have applications in the detection of cancer
by highlighting abnormal ductal structures and in the
planning and monitoring of its treatment by defining
interconnected functional regions or lobes.35

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3D Ultrasound Imaging of Mammary Ducts in Lactating Women

Ultrasound examination of the breast ducts is

also useful in the assessment and study of lactation
and associated problems. An understanding of the
breast anatomy is important6 within the field of
human lactation. The ability to assess the anatomy,
both of the breast and of the ductal systems, using
quantitative 3D ultrasound may enable further
research into lactation and breast-feeding.
Previous Studies of the Ductal/Lobular System
A number of previous studies have considered
the 3D ductal structure of the breast, although
this has been achieved largely by use of dissection and histologic sections rather than by use of
ultrasound imaging. Cooper7 injected each ductal/lobular system with colored wax, via the nipple, before dissection. This allowed the ducts to
be clearly distinguished during dissection and
the different lobes to be identified using different
colors. Figure 1 shows a drawing from such a dissection. Cooper7 noted that there were typically
only 7 to 10 openings on the nipple, which
allowed injection of wax for ductal dissection,
whereas he observed up to 22 straight tubes
within the nipple, suggesting that not all ductal
systems opened onto the nipple. Each of the
wax-injected openings led to separate ductal/lobular systems, showing these systems to be
isolated from each other. More recently, Going
and Moffat5,8 created a 3D anatomy of the ductal
system by manually tracing ducts from histologFigure 1. Artists drawing of the ductal structure of the breast
dissected by Cooper.7 Each ductal/lobular system was injected
with colored wax before dissection to illustrate the different
lobes. Reproduced with permission from the Thomas Jefferson
University Archives and Special Collections (Philadelphia, PA).

96

ic sections (2 mm thick) onto acetate sheets.

These manual tracings were then analyzed and
reconstructed using computer software. They
found large differences in the tissue volume
drained by different ductal systems within the
breast, with the largest lobe draining 23% of the
breast volume and the 8 smallest ductal systems
together only draining 1.6% of the breast volume.
Serial sections (100 m thick) through a nipple
from another breast5 revealed that only 7 of 34
ducts entering the nipple had an opening on the
surface of the nipple, whereas the remaining 27
terminated either at the base of the nipple or
about 1 mm below the nipple surface. Ohtake et
al4 performed a similar computer-assisted 3D
reconstruction of the ductal system from 2-mm
sections through a breast. The purpose of their
study was to identify anastomoses connecting
different ductal/lobular systems. Of the 16 ductal/lobular systems within a single breast, 2 anastomoses were found that connected otherwise
separate ductal/lobular systems.
Three-dimensional ultrasound mapping and
study of ductal systems has been limited.
Ramsay et al9 used 2-dimensional (2D) ultrasound to scan the breasts of lactating women
and recorded scans on video for later analysis.
The ultrasound images were annotated to give an
indication of the approximate position within
the breast, although no quantitative measurements of the location were made. Each main
duct was traced from the nipple back into the
parenchyma to the limits of detection by ultrasound, and various linear measurements were
made of each main duct (depth of the main duct,
distance to the first branch from the nipple, and
diameter and depth from the skin of branches).
However, 3D reconstruction or modeling of the
ductal systems was not performed, nor were
branches from the main duct examined in detail.
Moskalik et al3 used a stepper motor to drive a
linear array probe across the medial side of the
breast, away from the nipple, allowing the generation of a 3D ultrasound data volume for part of
the breast. This was performed for a single lactating breast of a volunteer. Manual tracing of ducts
enabled 3 ductal systems to be identified and
mapped within this volume. Therefore, a 3D
model of the ductal system could be produced
for a small section of the total breast volume.
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Overview of This Study

In this study, we sought to extend the work of
Moskalik et al,3 who suggested the development
of methods to scan the whole breast volume, and
to perform automatic mapping of all of the ductal/lobular systems. We show that 3D scanning of
most of the breast tissue is possible using a scanning system previously reported,10 and manual
tracking and display of the ductal systems are
feasible, at least in the lactating breast. In this
study, only manual analysis of the ultrasound
data was performed, with the aim of assessing
the feasibility of tracking ducts within such data.
Initial work toward the automatic detection of
ductal structures is reported elsewhere.11 Results
are presented from a study of 4 lactating volunteers. Finally, anatomic and functional observations from the study are discussed with reference
to previous literature.

Materials and Methods

Three-Dimensional Ultrasound Imaging
Only a brief overview of the 3D ultrasound acquisition system used for this research is given in
this section. The system has been described in
detail elsewhere10 and was designed to allow
acquisition of a data set including most of the
breast tissue, with only the axilla excluded. The
breast is scanned in a radial fashion using automated mechanical movement of a linear array
transducer from a commercial ultrasound scanner, together with video capture and digitization
of the ultrasound images. The breast tissue is
immobilized to acquire a consistent set of
images. The immobilization device is a 45 cone,
which supports the dependent breast as the
patient lies prone. The effect of breathing is minimized because the breast is dependent and constrained by the cone while the sternum is
supported by the scanning table, and the low
level of compression applied by the scanner is
advantageous in allowing the visualization of
ducts, which collapse at higher compressions.12
The linear array probe is held against a narrow
thin polymer film window so that the scan plane
lies along a radial plane. This plane was identified as valuable for imaging geometric features in
breast disease13 and allows the ductal structures
to be imaged approximately longitudinally.1 The
J Ultrasound Med 2010; 29:95103

transducer is held at a fixed height, and the

entire mechanism including the cone and
transducer is rotated about the breast through
at least 360. Overlapping rotations are completed with the transducer held at 2 or 3 heights, with
respect to the cone, if the length of the transducer is insufficient to image the complete breast in
a single rotation. Light mineral oil (Johnsons
Baby Oil; Johnson & Johnson, New Brunswick,
NJ) serves as both a lubricant and a coupling
agent between the breast tissue and the cone.
Ultrasound images are recorded throughout
each rotation from the output video signal using
a PCCOMP frame grabber (Coreco Imaging;
St Laurent, Quebec, Canada). A Technos ultrasound scanner (Esaote SpA, Genoa, Italy) was
used with a linear array probe (LA532, 134
MHz) at nominal frequencies of 12.5 and 9 MHz,
depending on the volunteer. Imaging parameters were visually optimized by a sonographer on
a case-by-case basis from the 2D images while
still allowing a frame rate in the range of 15 to 25
Hz. The system hardware is shown in Figure 2. It
should be noted that the height and size of the
cone can be adjusted to accommodate a range of
patients. The cone is shown in a lowered position
for illustrative purposes only.
The data are reconstructed into an isotropic
Cartesian voxel array using geometric information about the location of each image plane
derived from the height of the transducer against
the cone and the rotation speed. Nonrigid image
registration is used to correct for measurement
inaccuracies, speed of sound variations, and tissue movement.14,15 For this study, a voxel side
dimension of about 0.15 mm was used (exact
details in the next section).
Volunteers
In vivo acquisitions were performed with 4 volunteers using the 3D system described. The
acquisition protocol was approved by the institutions Ethics Committee, and all volunteers
gave informed consent to the acquisition. The
volunteers were lactating mothers who had successfully established a breast-feeding routine
with a single infant. Both breasts of each volunteer were scanned before a breast-feeding session. Relevant details of the volunteers and the
scans are given in Table 1.
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Analysis of the Ductal/Lobular System

Manual tracing of ductal structures was performed using custom software. This software
enables researchers to view the data set in the
radial and coronal planes. The center of each
duct was identified on each coronal plane, while
the radial plane was used by a researcher to
improve understanding of the ductal system
geometry and connectivity. An approximate
diameter of the duct was given at each center
point, although the ducts are not all cylindrical,
to give an approximate indication of the duct
size. Figure 3 shows the display presented to the
researcher, together with the added marks identifying the ductal structures. The 3D model of
the ductal systems was exported to 3D Slicer, a
medical visualization program created at the
Figure 2. Scanning hardware. Top, The patient lies prone on the
scanning table with the breast to be scanned positioned through
the hole in the table into the supporting cone below. The cone
is raised up to accommodate the breast. Beneath the cone is a
drip tray, to catch any stray coupling agent, and the stepper
motor housing and control. Bottom, Both the cone and probe
are rotated about the breast, as indicated by the arrow.

Massachusetts Institute of Technology Artificial

Intelligence Laboratory (Cambridge, MA) in collaboration with the Surgical Planning Laboratory
at the Brigham and Womens Hospital,16 such
that the arborescent structure could be displayed
and studied in 3D. In the 2D views, it was very
difficult to differentiate between ducts and blood
vessels because both appear as dark linear
structures. However, once the structures were
mapped in 3D, the different branching patterns
and orientations allowed the blood vessels and
ducts to be identified more easily because the
ducts radiated from the nipple, whereas the blood
vessels often followed the circumference of the
breast. Because of the time-consuming nature of
the manual analysis, tracing was performed by
separate researchers (M.H., M.J.G., J.F./F.A.D., and
J.A.S.) for each data set (14, respectively).

Results
Appearance of Ductal Structures in the
B-Mode Images
Figure 4 shows a standard B-mode ultrasound
image of a milk duct in a lactating breast. As
reported elsewhere,12 the duct appears as a
band of reduced echogenicity. Although the
duct can be easily visualized and its width measured, it is more difficult to gauge the 3D structure of the duct and ductal system: eg, the
out-of-plane width of the duct and the relative
locations of ducts. In-plane branching can be
observed (although not shown in Figure 4);
however, out-of-plane branching is more difficult to detect.
Analysis of the 3D Ductal/Lobular System
All visible ductal structures were manually
mapped for both breasts of each volunteer. The
findings for each volunteer were similar and are
summarized below.
Figures 5 and 6 show the 3D visualizations of
the ductal structures for the right and left breasts,
respectively, from volunteer 2. For all volunteers,
ducts were predominantly in the inferior lateral
quadrant of each breast. Figure 7 shows the
regions in which the ducts were predominant for
each volunteer. Figure 8 illustrates this, showing
the coronal plane for volunteer 3, where the
ducts can be seen as darker circular patches.

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Table 1. Details of the Volunteers and Settings Used in this Study

Characteristic

Age, y
Parity
Infant age, mo
Feeding schedule

Time since last feed

before ultrasound
scan, h
Scan depth setting, mm
3D data voxel edge
dimension, mm
Notes

Volunteer 1

39
3
11
5:30 AM, 3:45 PM,
8:30 PM, 2 or 3 times
during night
8, scan at 22:30 PM

Volunteer 2

36
3
10
8 AM, 3 PM, 9 PM,
2 times during night
6, scan at 22:30 PM

52
0.174

41
0.139
Volunteer said left breast
was more full with milk

In all volunteers, one breast contained ducts

that were noticeably wider than for the other
breast. This was generally in agreement with the
volunteers statement as to which breast felt
fuller and reflected from which side the infant
last fed, with the exception of volunteer 4. In that
instance, the ducts in both breasts were small
and therefore difficult to see, perhaps as a result
of the infant being almost weaned and thus the
demand, and presumably the supply, of milk
being reduced.
In cases of substantially enlarged ducts, the
presence of more milk in the breast made tracking of the ducts difficult because the boundaries
between ducts were poorly defined in the volumetric images, as shown in Figure 9 for volunteer
1. Therefore, it was necessary to make assumptions about connectivity to perform manual
tracing in such cases.
For all volunteers, the sections of the duct that
appeared enlarged were deeper in the breast
tissue and narrowed to the nipple. Narrower
sections were also observed between enlarged
sections. These enlarged areas can be seen in
the 3D models in Figures 5 and 6. Figure 10
shows a 2D slice for one such case for volunteer
3. In a number of cases, a duct that showed
enlargement over an extended range also
showed a number of very localized constrictions, as shown in Figure 11 for volunteer 2. The
cause of these constrictions is unclear. Further
investigation would be required to ascertain the
true cause.
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Volunteer 3

27
1
4
Short feeds hourly
during day, no information about night feeding
3, scan at 1:452:15 PM

Volunteer 4

35
1
19
8 AM, 1 PM, 7 PM,
none during night
5, scan at 33:30 PM

52
0.174
Volunteer said right breast
was more full with milk

52
0.174
Volunteer said left breast
was more full with milk

Discussion
Although the purpose of this study was to assess
the feasibility of 3D tracking and display of the
ductal/lobular systems over the entire breast volume, this small illustrative study raises a number
of interesting anatomic and functional questions
about the breast, such as the apparent absence of
an ampulla and the noticeable localization of the
regions of ductal activity in this group. These
observations are discussed below in the context of
previous studies. No firm conclusions can be
drawn because of the small size of the study presented here, and these issues will need more rigorous investigation to assess the degree of variation
between participants in a larger population.
Figure 3. Software used to manually trace the ductal structures within the 3D ultrasound data sets. The researcher used the coronal view (right) to mark the center of
the duct, shown with crosses, and the approximate diameter of the duct, shown
with circles. The radial plane (left) was used to assess the connectivity of the ductal sections. Center points and diameters are also shown in this plane. The yellow
lines illustrate the relative position of the other plane within the current view.

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Presence of Ampulla/Lactiferous Sinuses

Coopers wax-injected dissections7 revealed
widening of the duct beneath the areola, referred
to as the ampulla or lactiferous sinuses. He
attributed these to the need to store a small
quantity of milk to encourage the infant to initiate suckling when first presented to the breast.
Unfortunately, neither Going and Moffat5 nor

Ohtake et al4 made reference to the duct diameter or lactiferous sinuses within their histologically based 3D reconstructions of the ductal
structure within nonlactating breasts. Moskalik
et al3 reported locating the ampulla as a method
to find ducts within their 3D ultrasound study
and suggested that the ampulla would be a good
place for an automatic tracking algorithm to
detect the duct initially.
However, in our feasibility study, it was found
that widening of the duct generally occurred
after the first branching point, with respect to
the nipple, for most ductal sections identified.
Although on B-mode scanning the enlarged
parts of the duct may have appeared to be
beneath the areola, in agreement with the typical
description of ampullae, the presence of a
branching point between the nipple and the
widening is in disagreement with Coopers
description of the anatomy.7 Figures 5 and 6
show the 3D models of the ductal systems, as
delineated manually by the researcher, for the
left and right breast, respectively, with the associated duct widths included. Ramsay et al,9 who
observed from their ultrasound examinations of
lactating breasts that although the duct diameter
increased at multiple branching points, typical
saclike features behind the areola were not
observed. They noted that Coopers method of
injecting wax to visualize the ducts7 may have
forcibly expanded the ducts. The observations in
our study are in agreement with their opinion
that Coopers observation of enlargement of the
duct behind the nipple may not be a normal

Figure 5. Three-dimensional model of the ductal systems within

the right breast of volunteer 2. This model illustrates the estimated diameters of the ducts at each location. The various colors represent different connected sections of the ducts. The coronal section (left) is shown as if looking toward the volunteer. The 3D
view (right) is rotated to best illustrate the ductal tree.

Figure 6. Three-dimensional model of the ductal systems within the left breast of volunteer 2. This model illustrates the estimated diameters of the ducts at each location. The various colors represent different connected sections of the ducts, and the
red volume represents a blood vessel. The coronal section (left)
is shown as if looking toward the volunteer. The 3D view (right)
is rotated to best illustrate the ductal tree.

Figure 4. Typical B-mode ultrasound scan of a lactating breast.

The engorged duct can be seen as a dark band within the glandular tissue. One of the engorged ducts is identified by a arrow.
The 3D structure of the ductal system is hard to understand from
this view (width of scan, 4.5 cm).

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anatomic feature but rather a feature of his

method. Nevertheless, Coopers hypothesis that
some milk must be stored within the ducts to
provide instant gratification for the infant is illustrated by our observation of enlarged, milkladen regions within the ductal system.
Existence of Localized and Limited Ductal
Activity
In this small study, only about one-third of each
breast appeared to store milk, as detailed in
Figure 7. A similar observation was made by
Going and Moffat,5 who noted that in the histologic sections of a nipple from a lactating
woman, only 4 ducts appeared dilated, whereas
the rest were collapsed. They speculated that
only 4 ductal/lobular systems were contributing
substantially to milk production at the time of
mastectomy. However, Ramsey et al9 made no
reference to observing localized ductal activity in
their ultrasound study of 21 lactating women.
Moskalik et al3 also did not explicitly refer to any
localization of activity, having only scanned a
portion of the breast, but they did note that 2 (of
3) ducts appeared noticeably larger, potentially
as a result of enlargement caused by, or for the
purpose of, milk storage.
The localization observed during this study
may have originated from variable compression
of the breast within the cone, if the breast was
not central within the immobilizing cone.
However, the compression applied to the breast
by the cone is generally in the superior and inferior sections, which would lead to the observation of enlarged ducts both medially and
laterally. Because the regions of ductal enlargement do not correspond to this prediction, it is
probable that the localization of enlargement is
not a result of the scanning method but of actual
breast activity. In addition, the observations of
Going and Moffat5 support the view that not all
ductal systems within the breast are active during lactation. The reason for varying activity or
storage may be that the capacity of the breast to
produce milk exceeds the current demand. The
number of ductal systems within the breast, 15 to
20,1,4,5 also seems to exceed the number of openings at the nipple,5,7,17 suggesting that not all ductal/lobular systems can be active in lactation
regardless of demand.
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Figure 7. Diagram showing the regions of the breast with noticeable ductal activity for each volunteer. The shaded sections illustrate the regions of the breast
where enlarged ducts were observed within the 3D ultrasound scan. Most ductal
activity was observed in the lower outer breast quadrants.

Further investigation is needed to assess

whether this pattern of limited ductal activity or
storage is common and whether the localization
of active ducts is generally symmetric between
breasts or even follows a pattern among women
in general. An investigation of breast-feeding
women with twins may also indicate whether
more ductal/lobular systems are active when
the demand for milk is greater, or whether the

Figure 8. Coronal planes through the breast data volumes of volunteer 3 highlighting the sector of noticeable ductal activity. The active regions are illustrated
by arcs around the edge of the data. The dark regions indicated by the arrows
have been identified as blood vessels. The coronal sections are shown as if looking toward the volunteer with the left image showing the volunteers right breast
and the right image showing the volunteers left breast.

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3D Ultrasound Imaging of Mammary Ducts in Lactating Women

Figure 9. Coronal section through the right breast of volunteer

1 illustrating the poor definition of the duct boundaries, indicated by the arrows, on the coronal plane in regions with considerable ductal enlargement. The coronal section is shown as if
looking toward the volunteer.

demand is still met by a limited number of ductal/lobular systems producing more milk.
Performing ultrasound analysis during lactation
may also highlight whether this observation is
one of localized activity or localized storage.
Summary
A 3D map of the ductal/lobular structure of the
breast would have applications in a number of
clinical areas, including aiding clinical visualiza-

tion of 3D ultrasound data, detection and diagnosis of breast lesions, definition of surgical excision margins based on the extent of the
connected lobe rather than the lesion size, guidance in ductal endoscopy, and alignment of 3D
breast scans taken of the same breast at different
times. Further applications may be found in the
study of the anatomy and mechanisms of lactation and breast-feeding.
This study has built on the work of Moskalik et
al,3 showing that it is possible to perform 3D
mapping of mammary ducts from a 3D ultrasound scan of a lactating breast. Although this
feasibility study included only a few participants,
interesting clinical questions were raised as a
consequence of the mapping regarding the pronounced localization of engorged ductal/lobular
systems and the presence or otherwise of the
ampullae compared with conventional breast
anatomy.
Clearly, there is much scope for future research
into both the manual and automatic mapping of
the ductal/lobular system. Ultrasound visualization of the 3D structure of milk-laden ducts in an
uncompressed breast has been shown. Using
manual tracing, it was possible to track milkladen ducts of diameters less than 1 mm.
However, it was not possible to delineate all ducts
in the remainder of the breast. Improved ultrasound resolution will be necessary if complete
ductal mapping from 3D ultrasound is to be used
in the nonlactating breast, such as in the detection and diagnosis of breast lesions and guidance
of lobe size for surgical excisions.35
Figure 11. Radial section through a breast of volunteer 2 showing an enlarged duct with apparent sheetlike constrictions. The
cause of these constrictions is unclear.

Figure 10. Radial section through a breast of volunteer 3 showing sections of ductal enlargement and narrowing. For all volunteers, the duct always narrowed before the nipple.

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