Breast imaging

DR. Lina Mohsen Rida

DMRD
 Breast imaging modalities

1. X-ray
-Mammography
-Digital Breast Tomosynthesis (DBT)
-Xeromammography
-Galactography
2.MRI
3.Ultrasound
4.Scintimammography
5.Diffuse optical mammography
Digital mammography
Film screen mammography
T
• Home work : read
• X-ray tube. The most commonly used target-filter
combination is a molybdenum (Mo) target with 0.03
mm Mo filter. The peak kilovoltage is normally in the
range 26-30 kV and typically 28 kV.
• Target filter combination :
Mo/MO is suited to the average or small-sized
breast. Other combinations are suited for large
breasts , eg: Mo/ rhodium, Mo/palladium,
rhodium/rhodium.
 Standard views:
Lateral oblique (MLO)
Craniocaudal (CC)

b
a

c
Correct positioning for mediolateral oblique view. a = Nipple
i n profile. b = Pectoralis muscle visible down to level of the nipple.
c = Inframammary fold visible. d = Glandular tissue evenly compressed and
adequately penetrated
Mammography : *diagnostic
*screening
Mammography indications :
• Screening asymptomatic women aged 50 years and over
• Screening asymptomatic women aged 35 years and over who have a
high risk of developing breast cancer:
-women who have one or more first degree relatives who have been
diagnosed with premenopausal breast cancer
-women with histologic risk factors found at previous surgery, e.g.
atypical ductal hyperplasia
• Investigation of symptomatic women aged 35 years and over with a
breast lump or other clinical evidence of breast cancer
• Surveillance of the breast following local excision of breast carcinoma
• Evaluation of a breast lump in women following augmentation
mammoplasty
• Investigation of a suspicious breast lump in a man
Skin thikness:0.5—2 mm
The main duct branches repeatedly within the breast and the most distal
branches of the duct system are called the terminal ducts.
The terminal duct consists of extralobular and intralobular
portions. The intralobular portion, together with the acini, forms a
lobule. The extralobular terminal duct and the lobule form a terminal
ductal lobular unit (TDLU). The TDLU is the site of origin of most
malignant and benign diseases of the breast.
 Variant anatomy

• Breast hypoplasia: underdevelopment of the breast,

can be congenital or acquired.
• Amastia: absence of breast tissue, nipple and areola.
• Amazia : absence of glandular parenchyma in either one or
both of the breasts and a normal nipple and areola complex.
• polythelia (supranumerary nipple)
• polymastia (accessory breast tissue)
Accessory breast tissue/ normal variant
 Breast composition (density)

• Refers to the amount of fibroglandular tissue in a breast relative to fat. It can

significantly vary between individuals and within individuals over a lifetime.

There are four descriptors for breast density on mammography in the

5th edition of BI-RADS:

a: the breasts are almost entirely fatty

b: there are scattered areas of fibroglandular density
c: the breasts are heterogeneously dense, which may obscure small masses
d: the breasts are extremely dense, which lowers the sensitivity of
mammography
A B

C
D
 Calcifications
The level of suspicion for malignancy is assessed from analysis of
the mammographic signs on magnification views. The key features
that are analyzed are:

• Particle shape
• Particle density
• Cluster shape
• Distribution
 Suspicious calcifications
In general tend to be smaller and less regular than typically benign
calcifications .
• According to BI-RADS 5th edition lexicon , 4 descriptors of suspicious calcification
morphology on mammography, listed in order of increasing suspicion :
• Coarse heterogeneous: irregular, generally 0.5-1 mm
• Amorphous : indistinct and/or small ("powdery", "cloud", or
"cottony"), such that another specific shape cannot be
determined
• Fine pleomorphic: variable shape ("shards of glass" or "crushed
stone"), generally <0.5 mm
• Fine linear or fine-linear branching: thin (<0.5 mm), linear,
branching or irregularly arranged ("casting")
Suspicious calcification distribution: listed in
increasing order of suspicion  
• Regional : scattered in a larger volume (>2 cm in greatest linear dimension)
of breast tissue and not in the expected ductal distribution
• Grouped : a cluster of at least 5 calcifications within 1 cm from each other,
in an area at most 2 cm in greatest linear dimension
• Linear : calcifications arrayed in a line suggestive of deposition along ducts
• Segmental : calcium deposits in ducts and branches of a segment or lobe
---------------------------------------------------------------------------------------------

*(Diffuse is almost always benign)

*Punctuate calcifications can be suspicious if they are new, increased, or
linear or segmental in distribution
 Ultrasound
scanning technique

Probe linear array

7-13 MHz

Radial ultrasound scanning technique of the

breast. The breast is divided into four quadrants.
Each quadrant is scanned in a radial fashion to
accommodate the arrangement of ducts in the
breast.
Then each quadrant is scanned both vertically
and horizontally. Care should be taken that all
scans overlap to ensure scanning of the entire
breast.
The breast is scanned and described as a clock-face.
Begin at 12 o'clock in a sagittal plane with the toe of the probe at the nipple.
Scan by rotating the probe around the nipple.
Depending on breast size, a second pass further from the nipple may be
required.
If pathology is identified, rotate the probe 90degrees in the 'anti-radial' plane.
Breast composition
 Breast ultrasound indications

• Symptomatic breast lumps in women aged less than 35 years

• Breast lump developing during pregnancy or lactation
• Assessment of mammographic abnormality (± further mammographic
views)
• Assessment of MRI or scintimammography detected lesions
• Clinical breast mass with negative mammograms
• Breast inflammation
• The augmented breast (together with MRI)
• Breast lump in a male (together with mammography)
• Guidance of needle biopsy or localisation
• Follow of breast cancer treated with adjuvant chemotherapy
Typical US characteristics of solid breast
lesion
Findings in mammography
Mass shape and margin
 Margin
In order of increasing probability of malignancy, which can be
remembered by the mnemonic COMIS:

Circumscribed, i.e. more than 75% of the circumference is well

defined
Obscured , i.e. more than 25% of the circumference is hidden by
adjacent or superimposed fibroglandular tissue
Microlobulated , i.e. small undulations, which is usually
suspicious
Indistinct , i.e. none of the circumference is well defined, which is
usually suspicious
Spiculated , i.e. with sharp linear radiations, which is usually
suspicious
Well-defined lesions are more commonly benign

Benign lesions tend to be isodense or less dense than

the parenchyma and to have very circumscribed
margins.
Whereas ,
Malignant masses are more often of greater density
and have fine irregularity or micronodularity on their
borders.
 Cross -sectional ultrasound
image of milk ducts in the
lactating breast. On the left
image, milk ducts appear as
oval hypoechoic (black)
structures. On the right
image, milk ducts have
collapsed under minimal to
moderate compression with
the ultrasound transducer.

Longitudinal scan
Ducts can be
observed in the
nipple as
hypoechoic tubular
structures.
 oil cyst / Fat Necrosis

Oil cyst. A: Photographically coned

image of the right breast. An oval
lucent mass (arrow) with
circumscribed margins is identified.
This is pathognomonic of an oil cyst
with the diagnosis reliably established
on the mammogram. BI-RADS 2:
Benign finding. B: Ultrasound. An
anechoic mass (arrow) with some
posterior acoustic enhancement is
imaged corresponding to the oil cyst
seen on the mammogram.
Fat necrosis. A: Spot compression view done to evaluate a screen-detected abnormality.
An irregular mass with spiculated margins and distortion is confirmed on the spots (only
one projection is shown). B: A vertically oriented mass with angular margins and intense
shadowing is imaged in the upper inner quadrant of the right breast, zone B
corresponding to the mammographic finding. On questioning, the patient recalls having
had a fall one year ago with bruising of her right breast. The correlation with the clinical
history is critical because otherwise this lesion requires biopsy. It is our contention that
the correlation is best established by the breast imager. BI-RADS 2: Benign finding. The
mammographic finding has resolved on follow up screening studies.
Cystic mass with fat-fluid level galactocele. (a) Mammogram reveals an oval circumscribed
mass with the characteristic fat-fluid level (arrows). In this type of galactocele, the milk content is
fresh and fluid, allowing the fat to rise and the heavier water content to remain in the lower
portion of the cyst. (b) US image also demonstrates the fat-fluid level (long arrows), with typical
high and low echogenicity. Note that the fatty component has risen and occupies the upper
(nondependent) portion of the cyst, whereas the heavier water content remains in the lower
(dependent) portion. Note also the clot of fatty milk (“cream”) (short arrow) floating in the
nondependent portion of the cyst owing to its intermediate density.
 Fat containing/ mixed
density lesion

Fibroadenolipoma
A hamartoma or fibroadenolipoma is a benign
tumor composed of normal mammary tissue
(adipose, fibrous, and glandular), including ducts
and lobules of varying amounts
 Since the lesions are made
up of breast tissue, breast
cancer of any type can
arise in hamartomas .

From Cardeñosa G. Breast Imaging

[The Core Curriculum Series].
Philadelphia, PA: Lippincott
Williams & Wilkins; 2003.)
 Fat containing
lesions

Lymph nodes (LNs)

 Isodense , circumscribed masses

Simple breast cysts 

Are a common benign cause of a breast lump in women.
They can be classified according to size:

microcyst: <3 mm
macrocyst: >3 mm
Microcysts are found commonly in fibrocystic changes.
Mammography CC
MLO
Cysts appear as a breast
mass with the following
features:

oval or round shape

circumscribed margins

Multiple round masses

in both breasts is
suggestive.
Cyst
Ultrasound

The diagnostic sonographic features are the

following:
oval or round shape
anechoic (no internal echoes)
circumscribed margins
posterior acoustic enhancement

Other findings may include the following:

reverberation artifact
smooth walls
peripheral calcifications
 Isodense , circumscribed masses
 Fibroadenoma : is a common benign breast lesion and results from the excess proliferation
of connective tissue. Fibroadenomas characteristically contain both stromal and epithelial
cells.
Age : between 10 and 40 years.

Ultrasound

Typically :well-circumscribed,
round to ovoid, or macrolobulated mass
generally uniform hypoechogenicity. 
Intra lesional detectable calcification may be
seen in ~10% of cases  .
Thin echogenic rim (pseudocapsule) may be
seen.
Mammography
Spectrum of features : well-circumscribed discrete oval mass
hypo- or isodense to the breast glandular tissue, to a mass
with macrolobulation or partially obscured margin.
Involuting lesions in older, typically postmenopausal patients
may contain calcification, often classic coarse popcorn
calcification . In some cases the whole lesion is
calcified. Calcification may also present as crushed stone-
like microcalcification which makes differentiation from
malignancy difficult. 
HISTORY: A 49-year-old woman with a
palpable RT breast mass.

MAMMOGRAPHY: Bilateral MLO (A) and

CC (B) views show masses in both upper-
outer quadrants. On the LT , a large
circumscribed mixed-density
mass (arrow) is present, consistent with a
hamartoma.
On the RT, the palpable mass is high
density and irregular with indistinct
margins. An enlarged lymph node is also
seen in the RT axilla.
IMPRESSION: Hamartoma, LT breast,
carcinoma RT breast, metastatic to the
axillary nodes.
HISTOPATHOLOGY: RT breast: Invasive
ductal carcinoma with metastatic nodes in
the RTaxilla.
 Spiculated mass
is the commonest mammographic appearance of invasive ductal carcinoma
HISTORY: A 77-year-old woman who
presents for screening mammography.
MAMMOGRAPHY: Left MLO (A) and CC (B)
views show an irregular indistinct masslike
density in the upper inner quadrant. The
area appears to be distorting the
architecture. Considerations for this
appearance are carcinoma, especially
invasive lobular carcinoma; fibrocystic
change with sclerosing adenosis; and radial
scar.
IMPRESSION: Indistinct mass with
distortion; recommend biopsy.
HISTOPATHOLOGY: Radial scar.
 Spiculated
(stellate )masses

An invasive ductal carcinoma

(*) giving a stellate
appearance in the left breast
on MLO view.
There is associated thickening
of the skin (white arrows) well
appreciated on this digital
mammogram.
invasive ductal carcinoma
US:
irregular, spiculated margin hypoechoic
mass taller than wide , some posterior
shdowing .
Primary Signs of Cancer on Mammography Secondary Signs of Cancer on Mammography

Mass Nipple Inversion

Calcifications Architectural Distortion
Skin Thickening
Axillary Adenopathy
Skin Retraction
Tissue Asymmetry
Developing Neodensity
 • ew, larger and more conspicuous than on a
previous examination.

has to be differentiated from a mass

superimposition of normal breast tissue. normal variant

New , larger and more conspicuous than on a

previous examination.
An example of a
focal asymmetry seen on MLO
and CC-view.

Local compression views and

ultrasound did not show any
mass.
 Architectural Distortion
The normal architecture is distorted with no definite mass visible.

Schematic Representation of AD.

Intersecting pattern of AD ( A ) : radiating lines.
Common patterns of overlapping normal structures ( B and C ).
With normal structures, note the off-center intersections and continuous
visualization of individual lines as they extend through the questioned finding.
Normal overlapping structures (fibrous bands, ducts, and blood vessels)
create patterns resembling intersecting flight paths.
 Architectural Distortion(AD)

Thin lines or spiculations radiating from a point and focal retraction or

distortion of the edge of the parenchyma.
AD can also be associated with a mass, asymmetry, or calcifications

DDx
A, Screening mammogram shows
retraction of the interface between
the fibroglandular tissue and
subcutaneous fat ( arrow ) on the
mediolateral oblique (MLO) view. 

B, Spot compression MLO and

craniocaudal (CC) views more clearly
demonstrate AD with radiating lines
and no central mass. Diagnosis:
multifocal infiltrating carcinoma
with ductal and lobular features and
ductal carcinoma in situ.

*Abnormal Tissue Contours

AD with Abnormal Finding on US.
Screening mammogram ( A ) shows extremely dense
tissue with subtle radiating lines of AD ( arrow ) in the
subareolar region that is visualized on the CC view only.
This finding is confirmed on a CC spot view ( B ). On US,
there is an irregular hypoechoic shadowing mass in the 6
o’clock position ( C ). Biopsy revealed infiltrating ductal
carcinoma.
Seromas are collections of serous fluid that usually occur as a
complication of surgery, but can also be seen post-trauma.
 Fibrocystic change of the breast (diffuse cystic mastopathy)
is a benign alteration in the terminal ductal lobular unit of the breast with
or without associated fibrosis.

-non-proliferative (simple) FCC that includes simple breast cyst and/or fibrosis

(most common)
-proliferative that includes
*atypical epithelial cell hyperplasias of the ducts or ductules 
*sclerosing adenosis

Ultrasound

-prominent fibroglandular tissue in the area

of a palpable nodule; 
however, no discernible mass 
small cysts in the mammary zone
 Mammography
breasts show heterogeneous and usually dense parenchyma 
partially circumscribed masses may be present reflecting cysts
tea-cup, low-density round calcifications in multiple lobes

 cluster of teacup-like calcifications surrounded by dense fibrosis produces a picture typical

of fibrocystic change, as demonstrated on the two orthogonal mammographic projections.
The histological images below show that each of the individual calcifications on the
mammogram is a summation of numerous microscopic psammoma body-like calcifications.
Breast implant
BI-RADS 0 : is used when imaging is incomplete such as:

when further imaging or information is required, e.g. compression,

magnification, special mammographic views, ultrasound
when requesting previous images not available at the time of reading
In the screening setting, mammograms with suspicious findings should
generally be assigned BI-RADS 0 to indicate a callback/recall for
diagnostic evaluation.
In the diagnostic setting, a study should be reported as BI-RADS 0 only
if there is a need for further information (e.g. focused ultrasound or
outside prior exams) that is planned to be obtained at a later time.
BI-RADS 1 category under the breast imaging reporting and
data system is when no finding is present in an imaging
modality (not even a benign finding).
BI-RADS 2 is a benign category in . A finding placed in this category should have
a 100% chance of being benign. 
Examples of such lesions or findings include:
calcified fibroadenomas
multiple secretory calcifications
fat-containing lesions such as:
oil cysts
breast lipomas
galactoceles
mixed density hamartomas
cutaneous neurofibromas  : e.g. in neurofibromatosis type I (evidence of
sarcomatous change is change is considered very low)
intramammary lymph nodes
breast sebaceous cysts
simple breast cysts
breast implants
BI-RADS 3 is an intermediate category in the breast imaging reporting and data
system. A finding placed in this category is considered probably benign, with a
risk of malignancy between 0% and 2%.

Mammography
The BI-RADS Atlas, fifth edition, contains three mammographic findings that should be
categorized as BI-RADS 3 :
Grouped round calcifications
circumscribed, round or oval mass without calcification
focal asymmetry without calcification or architectural distortion
Ultrasound
The following sonographic findings may be categorized as BI-RADS 3 :
complicated cyst with uniform low-level echoes
microlobulated or oval mass composed of clustered microcysts (although 
BI-RADS 2 may be appropriate if the appearance is classic 7)
hypoechoic mass, circumscribed, oval, parallel, without posterior features or
with minimal posterior enhancement
hyperechoic mass with central hypoechoic to anechoic components and
surrounding edema consistent with, but not diagnostic of, fat necrosis
refraction shadowing without an associated mass
architectural distortion thought to be due to postsurgical scar