BREAST IMAGING
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WHAT IS MAMMOGRAPHY?
Mammography is a special
type of X-ray imaging used
to create detailed imaging of
the breast.
It uses low-kV X-ray, high
contrast, high-resolution film
and an X-ray system
designed specifically for
imaging the breasts.
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Definition of breast cancer:
Cancer that forms in tissues of breast,
usually ducts (tubes that carry milk to
nipple) and lobules (glands that make
milk).
Occurs in both men and women (male breast
cancer is rare)
Breast Cancer: Why Screen?
• High prevalence
• Improved outcome by treatment
during the asymptomatic period
• Significant impact on public health
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Mortality Reduction
Due to detection of cancers at smaller
size/earlier stage
– Mammographically visible 3-5 years before
palpable
– Increased detection of DCIS
Early stage disease is curable
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MAMMOGRAM
1- SCREENING MAMMOGRAM
2- DIAGNOSTIC MAMMOGRAM
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Screening Versus Diagnostic Tests
Screening evaluates a population of
ASYMPTOMATIC people at risk for
disease
Goals
– High sensitivity for disease
– Low false negative rate
– Lower specificity acceptable
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Diagnostic Accuracy of Screening
Mammography
Sensitivity in women > 50 y.o.
98% fatty breast •
84% dense breasts •
Specificity
82-98% •
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SCREENING VS DIAGNOSTIC
MAMMOGRAPHY
• Diagnostic mammography
– Patients with breast signs or symptoms (palp
lump, pain, nipple discharge)
– Patients with abnormality detected on screening
mammogram
– Performed under the supervision of a radiologist
– Additional specialized mammographic views
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Screening Mammography
Consists of two images of each
breast
– Craniocaudal (CC)
– Medial-lateral-oblique (MLO)
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CC
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Rt CC
Lateral
Outer
Medial
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Rt MLO
Upper
Lower
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NORMAL MAMMOGRAM
CC MLO
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THE SCREENING MAMMOGRAM:
What are radiologists looking for?
Masses
Calcifications
Other findings
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Case 1
55 y.o.
Screening mammogram
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ACS Screening Guidelines: Average
Risk
Annual mammography age 40 and older
– Reduction in mortality by 30-50%
Annual clinical breast exam age 40 and
older
– Q 3 years age 20-40
Self breast exam optional
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ACS Screening Guidelines
Annual mammography earlier if mother
or sister diagnosed with breast cancer
(10 years prior to age of relative’s
diagnosis)
MRI if at high risk for breast cancer
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SCREENING VS DIAGNOSTIC
MAMMOGRAPHY
Diagnostic mammography
– Patients with breast signs or symptoms
(palp lump, pain, nipple d/c)
– Important for breast signs or symptoms that
clinicians specify
Location (side, clock-face, distance from nipple)
Size and shape
Diagram
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VIEWS OF DIAGNOSTIC MAMMOGRAM
Main views:
1- Mediolateral oblique.
2- Craniocaudal.
Additional views:
1- Compression view for areas of suspicious
masses or asymmetric breast tissue.
2- Magnification view for suspicious
calcifications.
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Compression view
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Magnification
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Breast Ultrasound: Indications and
Imaging Role
Mammographically detected masses
Palpable masses after mammography (most)
Initial study for palpable masses
– Pregnant
– Lactating
– Less than age 30
Cyst versus solid
Solid masses: benign versus malignant
features
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Patient Recalled From Screening
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Simple Cyst
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Mammographic signs of benign breast
lesions
Benign masses tend to
be spherical with smooth
borders & if they contain
calcifications , it is
coarser( macro) & more
structured-punctate or
round & are of similar
density than that seen in
carcinoma .
Mammographic signs of malignant
breast lesions
Malignant lesions tend
to be of variable shape,
irregular
outline ,calcification (the
so called malignant
microcalcification-
calcification : different
particle shape, density&
the cluster shape is
irregular or triangular
pointing toward the
nipple ).
Warning Mammographic Signs of Breast Cancer
Clustered calcifications, microcalcifications
Spiculated mass (spiky lump) .
Assymetrical density of breast tissue.
Skin thickening .
Retraction (skin or nipple pulling inwards) .
Focal distortion (something is pressing on
tissue) .
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Microcalcifications are an important sign of
early breast cancer ,they are the dominant
abnormality in 90% of in situ carcinomas.
Technical advances in mammography
equipment have lead to significant
improvement in mammographic image
quality and changed the ability to detect
early breast carcinoma.
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Routine craniocaudal mammogram spot-magnification mammogram.
clustered of microcalcifications Shows better details
Histology revealed ductal carcinoma in situ
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Case : Suspicious Calcifications
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CASE : Benign Calcifications
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BENIGN CALCIFICATIONS
1-Skin or dermal calcifications.
2- Vascular calcifications.
3-Lucent-centered calcifications ( Fat necrosis ).
4- Egg-shell or rim calcifications( Fat necrosis or
calcification in cyst wall).
5- Coarse or popcorn calcification( Fibroadenoma).
6-Large rod like calcifications or secretory calcifications.
7- Round or punctate calcification ( less than 0.5mm).
8-Milk of calcium.
9-Suture calcification.
10-Dystrophic calcifications (Trauma, surgery and
irradiation).
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Dermal
calcifications
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Vascular
calcifications
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Lucent-Centered
calcifications
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Egg-shell or rim
calcifications
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Popcorn
calcification
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Secretory
calcification
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Punctate
calcification
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Milk of
calcium
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Suture
calcification
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Dystrophic
calcification
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Fibroadenoma:
well-circumscribed,
oval-shaped mass
with calcification
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FEATURES OF MALIGNANCY
1- Speculated mass
2- Architectural distortion
3- Asymmetry of breast tissue
4- Micro calcification
5- Dense mass
6- Skin thickening
7- Pathological lymph nodes
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Speculated mass
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Architectural distortion
A focal area of breast tissue appears
distorted with no definable central mass.
-Causes:
A- Malignancy.
B- Benign lesions as in cases of prior breast
injury or surgery or radial scar.
-Benign lesions don’t change overtime.
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Architectural distortion
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Linear and branching micro calcification
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Dense mass
CC
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Dense mass
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On the mammogram report
BIRADS CODING
CATEGORY 0 Incomplete ; needs further evaluation.
CATEGORY 1 Negative mammogram
CATEGORY 2 Benign findings.
CATEGORY 3 Probably benign finding- short interval
follow up is suggested.
CATEGORY 4 Suspicious abnormality- Biopsy should be
considered.
CATEGORY 5 Highly suggestive of malignancy –
Appropriate action should be taken
CATEGORY 6 Proven malignancy
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