Imaging Work-up of Breast Clinical
Findings & Mammographic Abnormalities
Cristina Campassi, M.D.
Advanced Radiology, Baltimore, MD (USA)
XLVIII Congreso Medico Nacional
Managua, Nicaragua
June 1, 2017
Escenarios clínicos comunes en
imagen mamaria
Dra. Cristina Campassi, Radióloga
Advanced Radiology, Baltimore, MD (USA)
XLVIII Congreso Medico Nacional
Managua, Nicaragua
June 1, 2017
Lecture Objectives
•Review indications for mammography and
ultrasound
•Understand imaging diagnostic work-up of
patients with breast symptoms
•Explain principles of evaluation and follow-up of
imaging abnormalities
Mammography: Indications
•Screening Mammography
• Examination performed in asymptomatic women to detect
unsuspected breast cancer.
•Diagnostic Mammography
• Examination performed to evaluate patients with:
• Clinical signs and symptoms of breast disease
• Imaging findings requiring additional evaluation
• Imaging findings requiring follow-up.
ACR Practice Parameters
Standard Mammographic Views
Cranio-Caudal (CC) view Medio-Lateral Oblique (MLO) view
Screening Mammogram
•Two standard views of each breast (CC and MLO
views)
•Image quality is checked by the technologist
•Batch read or online reading
•Patient informed in writing of the results within
30 days
•Recall rate 5-12%
Diagnostic Mammogram
•Symptomatic patient
•New lump, palpable thickening, skin changes,
nipple discharge, focal pain, adenopathy
•Abnormal screening mammogram
•F/U probably benign mammographic finding
ACR Practice Guidelines
Diagnostic Mammogram
•Standard mammographic views
•Supplementary, specialized views
•Interpreted real-time
•Ultrasound performed same day
•Same day results to patient
Additional Mammographic Views
Spot Magnification CC view
Breast Ultrasound: Indications (1)
•All masses
•Palpable
•Non-palpable, imaging detected masses
•Evaluation of breast related signs and symptoms
•Pain, skin and nipple changes, nipple discharge, adenopathy
•Evaluation of imaging findings
•Mammogram: mass, asymmetry, architectural distortion, some
calcifications, adenopathy
•MRI: mass, non-mass like enhancement, adenopathy
ACR Practice Guidelines
Breast Ultrasound: Indications (2)
•Evaluation of breast implants
•Guidance of interventional procedures
•Planning for radiation therapy
•(Screening for high risk patients with dense breast tissue)
•Study of choice in patients under 30 years of age and
pregnant or lactating women for evaluation of palpable
masses
ACR Practice Guidelines
Palpable Breast Lump
24 year old female with history of palpable mobile left breast lump.
Diagnosis: Fibroadenoma
Lecture Objectives
•Review indications for mammography, ultrasound
•Understand imaging diagnostic work-up of
patients with breast symptoms
•Explain principles of evaluation and follow-up of
imaging abnormalities
Imaging Work-Up Clinical Breast Symptoms
•Palpable lump
•Nipple discharge
•Pain
•Palpable axillary adenopathy
Breast Lump: Imaging Evaluation
• Ultrasound
• <30 y/o female and male patients
•Pregnant and breast feeding women 30
•Mammogram and ultrasound
•>30 y/o female and male patients
• Correlation of clinical and imaging findings
Palpable Breast Lump
•45 year old female presenting for evaluation of
palpable soft, mobile left breast lump
Palpable lump is a fat
containing mass on
mammogram.
BIRADS 2 = Benign
finding
Diagnosis: Hamartoma
Recommendation:
Clinical follow-up
45 y/o male patient with tender palpable subareolar right breast lump
Palpable lump is an irregular complex cystic mass.
BIRADS 4 – Suspicious finding
Diagnosis: Abscess
Recommendation: Aspiration or biopsy
Palpable Breast Lump
Palpable lump is a spiculated mass at 12:00, highly suspicious on mammogram and US
BIRADS 5 = Highly suspicious for malignancy
Recommendation: Ultrasound guided biopsy
Diagnosis: Invasive Ductal Carcinoma
Breast Lump: Management
• Cyst
•No follow-up or intervention unless symptomatic
• Complex cystic solid mass and solid mass
•BIRADS 4
•Ultrasound guided biopsy
Nipple Discharge
•Bloody and spontaneous clear nipple discharge
•Clinical correlation with trigger point
•Mammogram with magnification views
•Ultrasound
•Breast MRI
•Ductogram
Nipple Discharge
•29 y/o female patient with right bloody nipple
discharge
•History of surgical biopsy of the left breast for
benign intraductal papilloma
Finding: Multiple intraductal masses.
BIRADS 4 = Suspicious finding
Recommendation: Ultrasound guided vacuum ass. biopsy
Diagnosis: Multiple papillomas
Nipple Discharge: Management
•Pathologic nipple discharge
•Mammogram + ultrasound
•Both examinations negative = surgical consultation
•Suspicious imaging finding = biopsy
Breast Pain: Imaging Evaluation
• Ultrasound
40
• <40 y/o patients
•Mammogram and ultrasound
•>40 y/o patients
Axillary Adenopathy: Ultrasound Criteria
• Hilum –
absent or
diminutive
•Eccentric
cortical
thickening
•L/T<2 or
round shape
Vassallo et al Radiology 1992; 183: 215-220
Lecture Objectives
•Review indications for mammography, ultrasound
•Understand imaging diagnostic work-up of
patients with breast symptoms
•Explain principles of evaluation and follow-up of
imaging abnormalities
Mass, Architectural Distortion,
Asymmetries Seen at Screening
•Additional mammographic views (spot or spot
compression)
• Spot or spot magnification in same projection that
shows finding
•Other views: 900, true lateral, rolled views
•Ultrasound
• Usually done for masses and architectural distortions
•Optional for asymmetries
Mass on Screening
55 years old asymptomatic woman’s screening shows a
6mm focal asymmetry or indistinct mass
RMCC RMMLO
Finding: 6 mm indistinct mass @ 9:30, right breast, on
mammography, solid on ultrasound.
BIRADS 4: SUSPICIOUS
Recommendation: Ultrasound guided breast biopsy
Diagnosis: Invasive ductal carcinoma
Calcifications: Magnification Views
•Additional mammographic views
•Spot magnifications views always in CC and 900
•Skin localization - Dermal calcifications
Calcifications: Milk of Calcium
Calcifications: Mag CC & ML Views
ML
CC
Calcifications Work-Up
•Magnification views
•Ultrasound
•Calcifications likely within fibrocystic changes
•Selected cases of extensive calcifications
•Calcifications with (linear, segmental) distribution suspicious for DCIS
•Suspicious calcifications likely associated with a mass
•Biopsy suspicious calcifications:
• Stereotactic or ultrasound or surgical biopsy
Screening detected 6 mm mass with calcifications
Magnification views: Indistinct mass with pleomorphic
calcifications
Ultrasound: Indistinct mass with calcifications
Recommendation: Ultrasound guided biopsy
Diagnosis: Papillary DCIS
Screening Breast
Mammogram symptoms
Abnormal Diagnostic MG &/or US
Negative Benign Imaging Probably Suspicious finding Suspicious finding
or Benign & Clinical Benign visible on US visible on MG
Screening Clinical F/U + Short Term US biopsy Stereotactic Bx or
Resume F/U MG MG Needle Loc
Screening &/or US Surgical Biopsy
Benign High Risk Lesion
6 or 12 mo F/U Pathology or Malignancy
Diagnostic MG or Non Excisional
&/or US Diagnostic Bx Biopsy or
Treatment
Thank You!
¡Gracias!
