Mammography and Breast Localization for the

Interventionalist
Wan-Hua Liu, MD, Gao-Jun Teng, MD, PhD, and Jing Jiang, MD

The goal of any physician practicing breast imaging and interventions is to identify breast
cancers at their earliest so as to best affect patient outcomes. As screening mammog-
raphy is the most widely used diagnostic tool in the detection of breast cancer, a
thorough understanding of mammography and potential benign and malignant findings
are a core requirement for breast imagers and interventionalists. Once identified, tumors
must be surgically removed. Mammographic guided breast needle localization is a basic
yet essential and very important procedure to facilitate proper surgical removal of breast
cancer with a high degree of accuracy and lowest possible patient morbidity.
Tech Vasc Interventional Rad 17:10-15 C 2014 Elsevier Inc. All rights reserved.

KEYWORDS Mammography, Breast lesion, preoperative localization

Basics of Mammography provides a more accurate assessment of the density of

Breast compression and positioning are major consider-
ations for obtaining higher-quality mammograms. Prop-
erly applied compression is one of the most neglected and
most important factors affecting image quality in mam-
mography. A primary goal of compression is to uniformly
reduce thickness of the breast so it is more readily and
evenly penetrated by the x-ray beam from the subcuta-
neous region to the chest wall. Without the compression of
the tissues, the image is less clear and does not provide the
same level of information. Advantages of adequate breast
compression are to reduce geometric unsharpness by
bringing the object closer to the detector, improve contrast
by reducing scatter and enabling use of a lower kVp beam,
diminish motion artifact by permitting shorter exposure
times and immobilizing the breast, and reduce radiation
dose by decreasing the thickness of breast tissue that needs
to be penetrated. To achieve more uniform density, a
homogeneous breast thickness prevents overpenetration of
the thinner anterior breast tissues and underpenetration of
the thicker posterior breast tissues. Adequate compression
The research was supported by research funds that comes from the
research of “National Key Basic Research Program of China”
(2014CB744504).
Department of Radiology, Zhong-Da Hospital, Southeast University,
Nanjing, China.
Address reprint requests to Wan-Hua Liu, MD, Department of Radiology,
Zhong-Da Hospital, Southeast University, 87 Ding-Jia-Qiao Rd,
Nanjing 210009, China. E-mail: liuwanhua.com@126.com
10 1089-2516/14/$ - see front matter & 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.tvir.2013.12.003
masses as normal glandular tissues are more easily com-
pressed and denser masses are highlighted.
To separate superimposed breast tissues so that lesions
are better seen, correct positioning is an important factor in
evaluating clinical images. During a routine mammogram,
each of the breasts is imaged separately with 2 different
views of each breast. Each view shows somewhat different
details and territory. The basic views are the craniocaudal
(CC) view—from above a horizontally compressed breast
(Fig. 1A) and the mediolateral (ML)-oblique—from the
side and at an angle of a diagonally compressed breast
(Fig. 1B). Other views may be taken for a diagnostic
purposes including lateromedial—from the outside
toward the center; ML—from the center toward the out-
side; spot compression—compression on only a small area
to get more detail (Fig. 1C); cleavage view—both breasts
compressed, to see tissue nearest center of chest; and
magnification—to see borders of structures and calcifica-
tions (Fig. 2).
The Different Types of Breast
Tissue
The radiographic appearance of the breast on mammog-
raphy varies among women and reflects variations in
breast tissue composition and the different x-ray attenu-
ation characteristics of these tissues. Fat is radiologically
lucent and appears dark on a mammogram. Connective
and epithelial tissues are radiologically dense and appear
Mammography and breast localization for the interventionalist 11

Figure 1 A 46-year-old woman with invasive ductal carcinoma in the upper outer quadrant of the right breast. The
mass is not well shown in CC view (A) and MLO view (B) because of surrounding dense parenchyma. The mass
with calcification is clearly shown in the spot compression (C), and we get more detail of the mass. MLO,
mediolateral-oblique.

light. These variations in appearance are commonly
described as the percentage of the breast image that is
radiologically dense or as percent mammographic density.
The percent mammographic density is a strong and
consistent risk factor for breast cancer.1 Women with
dense tissue occupying more than 60%-75% of the breast
are at 3-6 times greater risk of breast cancer than women
with little or no dense tissue.2 Breast density is inversely
associated with age, parity, and weight and is reduced by
menopause and by tamoxifen.
To date, 5 principal methods have been used to assess
mammographic density. Wolfe3 described 4 categories of
breast density: N1 (predominately fat), P1 and P2 (ductal
prominence in “less than one-fourth or more than one-
fourth,” respectively, of the breast), and DY (extensive
“dysplasia”). The American College of Radiology Breast
Imaging Reporting and Data System (BI-RADS) also
has categories of mammographic breast density from 1-
4. Other methods include visual estimation of the
proportion of the breast occupied by radiologically dense
breast tissue,4 planimetry,5 and computer-assisted meth-
ods of measurement that are based on interactive
thresholding.6
The Wolfe categories have largely been replaced in
the literature by quantitative methods of classification
or by the BI-RADS score. The classification method of
BI-RADS has 4 categories of mammographic breast
density.7
ACR 1: breast tissue that is almost entirely fat (o25%
glandular),
ACR 2: breast tissue that has scattered fibroglandular
density (25%-50% glandular),
ACR 3: breast tissue that has heterogeneous density
(51%-75% glandular),
ACR 4: breast tissue that is extremely dense (475%
glandular).
It is very easy to locate the lesion for breast composition
type 1 (Fig. 3A and B). It is much more difficult to analyze

Figure 2 A 36-year-old woman with the artifact due to residue of plaster. Residue of plaster can be seen in the inner
quadrant of the right breast (A). It is similar to microcalcification. After cleaning with water, the residue of plaster
disappears (B).
12
Figure 3 A 61-year-old woman with invasive ductal carcinoma in
the posterior outer quadrant of the left breast. Mass is clearly
shown on the type 1 mammogram CC view (A) and MLO view
(B). MLO, mediolateral-oblique.
and locate the lesion in the mammogram for breast
composition type 4 (Fig. 4A-C).
Benign and Malignant Findings
of Breast Lesions on
Mammography
The characteristics and definitions of benign and malig-
nant lesions on mammography are recommended by the
established BI-RADS. Mass is the most common finding for
benign and malignant lesions. A true mass is a space-
occupying lesion persisting in 2 different projections after
appropriate evaluation is completed. To successfully rec-
ommend appropriate management, several features of
the mass should be evaluated. A description of the shape,
margin, and density allows an organized analysis and
recommendation.
Figure 4 A 49-year-old woman with invasive ductal carcinoma in the inner quadrant of the right breast. Mass is not
very clear on the type 4 mammogram CC view (A) and MLO view (B). But the mass is displayed in the spot
compression (C). MLO, mediolateral-oblique.
W.-H. Liu, G. Teng, and J. Jiang
The shape of a mass may be categorized as round, oval,
lobulated, or irregular. The typically malignant mass has
a stellate or starburst appearance with an irregular contour.
The typical benign mass has a very different mammo-
graphic appearance, showing smooth contours and a
round or ovoid shape. The presence of lobulation within
a mass often complicates interpretation. Multinodular
masses frequently prove to be malignant. These lesions
should always be biopsied. On the contrary, most nodular
masses represent fibroadenomas that have only 1 or 2
gentle lobulations, often not raising sufficient radiographic
suspicion of malignancy to trigger biopsy.
The margin of a mass can be characterized as circum-
scribed, obscured, microlobulated, indistinct, and spicu-
lated. Most benign lesions are characterized as
circumscribed or well-defined lesions (Fig. 5). Margins of
these lesions are sharply demarcated with an abrupt
transition between the lesion and the surrounding tissue,
which reflects the absence of infiltration. The edges of
most breast cancers are poorly defined. A mass with fine
lines radiating from its margins is said to be spiculated and
is the most suspicious margin feature for malignancy
(Fig. 6). For some lesions, some of the margins are
seen to be very defined whereas others are obscured by
the adjacent isodense tissue. This usually confounds
mammographic interpretation, resulting in an equivocal
or indeterminate diagnosis. A supplementary spot com-
pression mammogram may prove helpful in this circum-
stance. Imaging with ultrasound or magnetic resonance
imaging can provide additional characterization of such
a mass.
Breast masses may be classified by density as either high
density, isodensity, low density (excluding fat density), or
fatty density. The x-ray attenuation of mass is related to the
attenuation of an equal volume of fibroglandular breast
tissue. Breast cancers are most often of equal or higher
density than glandular elements. Fatty density masses
include all lesions containing fat, such as lipid cysts,
lipomas, and galactoceles as well as mixed lesions such
Mammography and breast localization for the interventionalist
Figure 5 A 36-year-old woman with a fibroadenoma in the upper
outer quadrant of the right breast. A round high-density mass is
displayed. The mass is characterized as having a circumscribed
margin.
as hamartomas. Because there are no reported examples of
fat-containing breast malignancies, the importance of this
finding is obvious.
Calcifications are another important finding. In BI-RADS,
calcifications are divided into 3 categories: typically
benign, intermediate concern for malignancy, and high
probability of malignancy. When reporting on calcifica-
tions, it is important to describe the morphology of each
element of calcification as well as its distribution within the
breast.
There are 10 types of benign calcifications. Dermal
calcifications are typically lucent-centered deposits around
the areola, axilla, cleavage line, and inframammary por-
tions of the breast. They tend to be either clustered or
Figure 6 A 50-year-old woman with invasive ductal carcinoma of
the left breast. An irregular, high-density mass is shown on a
magnification mammogram. The edges of the mass are poorly
defined with spiculated and lobulated findings.
13
Figure 7 A 41-year-old woman with fibroadenoma of the right
breast. A mass with popcorn calcifications is displayed on the
magnification mammogram. Most of the margin is not very clear
owing to it being obscured by surrounding breast tissue.
diffuse with a regional distribution. Vascular calcifications
occur as parallel tracks or linear tubular calcifications that
are clearly associated with blood vessels. Coarse or
popcorn calcifications are frequently larger than 2-3 mm
in diameter, and these have the typical appearance of
calcified fibroadenomas (Fig. 7). Large rodlike calcifica-
tions are benign. These calcifications form continuous rods
that are occasionally branching and usually 1 mm or more
in diameter. This is the type of calcification found in
secretory disease and duct ectasia. Round calcifications
may vary in size and are usually considered benign. When
less than 1 mm, they are frequently formed in the acini of
lobules. When less than 0.5 mm, they are considered
punctate and warrant close follow-up or biopsy. Spherical
or lucent-centered calcification deposits may range in size
from less than 1 mm to more than 1 cm or more. They are
smooth and round or oval with a lucent center. When the
wall of these lucent-centered calcifications is thin, usually
considerably less than 1 mm, the term rim or eggshell
calcification may be used. They usually represent calcifi-
cation of the wall of a cyst, lipid cyst, or fat necrosis. The
varying appearance of calcifications on different mammo-
graphic projections is typical for milk of calcium. On
the CC image, they are often less evident and appear as
fuzzy deposits, yet on the horizontal beam lateral, they are
sharply defined with a semilunar, crescent, or linear
configuration. Milk of calcium occurs in cystic hyperplasia,
which can be included in the broad classification
of fibrocystic changes. Suture calcifications are typically
linear or tubular in appearance, and knots are fre-
quently visible. Dystrophic calcifications are usually mac-
rocalcifications and coarse and irregular, often with lucent
centers.
Calcifications of intermediate concern include amor-
phous and coarse heterogeneous calcifications. Approx-
imately 20% of these calcifications turn out to be
malignant.
14
Figure 8 A 59-year-old woman with invasive ductal carcinoma
with ductal carcinoma in situ of the right breast. Small, hetero-
geneous, and pleomorphic calcifications are shown. They are
segmentally distributed.
Malignant calcifications may appear alone or be asso-
ciated with a mass. Approximately 50% of invasive breast
cancers contain malignant calcifications. The calcifications
typically are small, heterogeneous, and pleomorphic. They
have jagged and irregular borders and tend to be linear
branching or segmentally distributed or in clusters (Fig. 8).
Architectural distortion is not an uncommon finding for
breast lesions. It includes spiculation radiating from a
point with no definite mass visible. This appearance can
also include focal retraction or distortion of the edge of the
breast parenchyma. If architectural distortion stands alone,
it may indicate a benign lesion such as a postoperative scar.
If architectural distortion is associated with a mass,
asymmetric density, and calcifications, the possibility of
malignancy is very high.
Figure 9 A 56-year-old woman with invasive ductal carcinoma in the inner upper quadrant of the left breast. A
fenestrated compression grid is used to localize the lesion in the ML view and the needle is inserted to enter the
skin parallel to the chest wall (A). With the needle in place, a repeat mammogram is obtained to check position (B).
The needle is removed, the wire hooks onto breast tissue (C). After resecting the lesion, the specimen is checked
(D). (Color version of figure is available online.)
W.-H. Liu, G. Teng, and J. Jiang
Preoperative Localization for
the Nonpalpable Breast Lesion
The large number of nonpalpable lesions detected mam-
mographically has led to the increased use of preoperative
localization techniques. This technique entails precise
radiologic localization preoperatively to aid the surgeon
in finding the lesion being biopsied and permitting its
removal with the smallest amount of breast tissue possible
so that the breast is not deformed by the biopsy. Before the
lesion is localized, its location in both the CC view and
ML views must be determined. If the lesion is shown in
only a single view, localization may be very difficult.
Various techniques for localization have been described
by ultrasound, stereotactic, or x-ray guidance. At present,
the use of combination needle and hooked wire technique,
under x-ray guidance, is very common. Following inser-
tion of the needle, correct placement is verified by
mammography.
The localization procedure is usually performed with
the patient sitting or standing and without premedication.
A fenestrated compression grid can be used to help localize
the lesion in a view (ML or lateromedial view is often used)
before needle insertion. The skin is cleansed with Betadine
solution or ChloraPrep. A 5 mL volume of 1% lidocaine
local anesthetic is given at the site of needle insertion and
in the tissues along the plane of the needle. The needle is
inserted to enter the skin parallel to the chest wall. With
the needle in place, a repeat mammogram is obtained to
check position. The needle is adjusted and rechecked
mammographically in another view (usually CC view). If
a needle containing a hook wire is properly positioned, the
needle is then removed while the wire is held in place. The
wire hooks onto breast tissue, anchoring itself. A length of
wire extends out beyond the skin. The mammogram is
again repeated. This film is sent along with the patient to
the surgeon.
An alternative method of needle localization uses
methylene blue dye. The lesion or calcifications are
Mammography and breast localization for the interventionalist
localized using either a CC or a lateral approach. After
cleansing the skin and administering local anesthetic, a
22-gauge spinal needle is advanced to the lesion or calcifi-
cations. Once adequate placement has been confirmed in
2 projections, approximately 0.3 mL of methylene blue
dye is injected through the spinal needle into the breast.
The needle is slowly withdrawn and the exit site on the
skin is stained with a drop of methylene blue. The skin exit
site is also marked with an indelible ink magic marker.
The procedure can be performed the day of or day before
surgery.
Other methods of breast localization described in the
literature include preoperative radioactive seed implanta-
tion localization and intraoperative creation of an ice
ball using a cryoprobe at the site of the lesion or
calcifications.8,9 These techniques are not widely accep-
ted as means of localization at the time of this publication
but may be useful in a certain subset of patients in the
future.
After tissue has been excised, the adequacy of excision
for all lesions is checked with specimen radiography before
the biopsy procedure is terminated. This step is essential.
Its purpose is to understand if the targeted lesion was
resected completely (Fig. 9A-D).
15
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