Mammography Guide to Interpreting, Reporting and Auditing

Mammographic Images Re.Co.R.M. (From Italian Reporting

and Codifying the Results of Mammography)

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 CONTENTS

FOREWORD IX

PREFACE XIII

PART 1 MAMMOGRAPHY TERMINOLOGY 1

THE NORMAL BREAST 3
RADIOLOGICAL ANATOMY OF THE BREAST 4
VARIATIONS OF NORMAL 11
MAMMOGRAPHIC SIGNS 23
Opacity " ." ." , " ." , " , . .. . . . . .. . . . . . .. 25
Circumscribed opacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27
Stellate opacity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 55
Diffuse opacity 75
Architectural distortion 81
Calcifications 97
Probably benign calcij1cations 129
Doubtful or indeterminate calcifications 179
Probably malignant calcifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203
Radiolucency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 227
Asymmetry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 235
Focal asymmetric density 239
Skin thickening and retraction 243
Oedema ,. 247
Asymmetrically dilated ducts 253

VII
PART 2 INTERPRETING AND REPORTING 255
INTERPRETATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 256
COMMUNICATION AND LANGUAGE 260
The RE.Co.R.M. DIAGNOSTIC ASSESSMENT CATEGORIES 266

PART 3 MAMMOGRAPHY AUDIT 269

VIII
FOREWORD

When Enzo Lattanzio showed me his book and asked me to write the foreword for it, I took one look and
said: "It's too big. It won't fit into a regular bookcase." Enzo looked me straight in the eye and replied: "It
doesn't belong in a bookcase, it belongs on a desk, where it can be delved into constantly."

Senology is not a branch of medicine like ophthalmology, rheumatology or cardiology: it is a discipline that centres
around a single organ and involves a slew of specialists, including radiologists, surgeons, pathologists, oncologists,
gynaecologists, and more. Each is called upon to contribute special skills and they must indeed have very special
skills in their own particular area. Thus, though senology can and does exist, there is no such thing as a "senolo-
gist." Senology is a highly complex discipline but still, when there is no disease, or where there are only benign le-
sions, imaging techniques can answer virtually all questions.
An hourglass is a good metaphor for describing how breast disease is tackled from many different quarters. The lo-
wer part of the glass represents the preclinical investigations, functional tests and epidemiological analyses. Diagno-
stic imaging occupies the "waist", and all the other specialties are in the top half. Breast imaging takes up little
space, but it is fundamental: without it the top half of the hourglass will collapse and the bottom cannot hold it
up and prevent disease taking over. Diagnostic imaging can detect lesions small enough to be successfully treated,
and has given extraordinary impetus to the fight against breast cancer. It has also contributed significantly toward
making senology a recognized discipline. It was mammography that brought it to the forefront: when Charles M.
Gros realized that a dedicated instrument was required to explore the breast, mammography became the driving
force behind senology. The quality of mammograms has gradually improved and the radiation doses are now smal-
ler. The art of interpreting these images has become increasingly refined and we can now characterize even the ti-
niest lesions.
Senology is becoming increasingly complex: though many other techniques have challenged mammography, some
providing both morphological and functional information, none have yet matched its ability to offer diagnostic hypo-
theses of sufficiently high predictive value, and it is still the only technique that can detect lesions only a few hun-
dred microns in diameter.
However, science marches on relentlessly. Molecular biology will surely sooner or later completely solve breast pro-
blems upstream of the diagnostic stage, but in the meantime other diagnostic approaches focussing more on the
 functional side such as MRI, contrast-enhanced US and PET, are starting to reveal the limits of mammography,
which, despite the advent of digital systems, is still based on morphology. In addition, the spread of methods in-
volving needle biopsies for cytology or histological examinations might suggest that the careful analysis of subtle
mammographic findings of small lesions is redundant - considering mammography as a technique belonging more
to the field of perception than to the field of diagnosis and characterization. Nothing could be further from the
truth. If every lesion - small or large - w ere biopsied, w om en might be reluctant to agree to regular check-ups
and all our efforts to promote prevention w ould be in vain.
So much has been learnt over recent years that radiologists can no longer afford to regard mammograms w ith the
cocksure diagnostic certainty of the past. Until science discovers the secret of preventing cells from turning mali-
gnant, and can offer truly effective therapy at any stage of the disease, and until new diagnostic techniques are de-
veloped that can supply accurate, repeatable and affordable functional or morpho-functional information, mam-
mography remains the only viable method for detecting most tumours early enough for effective treatment, wi-
thout unnecessary biopsies or other invasive procedures.
Therefore it is still essential to distinguish between what is decidedly negative on a mammogram, as opposed to
what needs regular monitoring, and what requires a needle biopsy. The secret of making such distinctions accu-
rately is to understand and learn to interpret the most subtle signs typical of breast lesions, thus acquiring kno w-
ledge and skills. This book provides all the necessary resources.
The American College of Radiology's BI-RADS® (Breast Imaging Reporting and Data System) and the ANAES
(Agence Nationale d'Accreduation et d'Evaluation de la Sante) guidelines have shown the way, emphasizing the
validity and importance of mammography, but many practitioners are still unfamiliar w ith breast imaging techni-
ques. This book will undoubtedly provide valuable support for physicians everywhere: it practically ensures suc-
cess.
It goes without saying that this is more than just a collection of images; contributions from many sources have been
welcomed, used and improved. All the images have been painstakingly selected and reproduced to the highest stan-
dards to make then as easy as possible to consult and memorize.
I was delighted to accept the invitation to write this foreword because it obliged me to read the book thoroughly,
and I am happy I did because it gave me a chance to put my kno wledge to the test and acquire valuable new in-
sights. All too often people of my age and position believe that textbooks like this are for younger colleagues, or
newcomers venturing into this area the first time. We often leaf quickly through the pages and take it for granted
that w e already know all there is to kno w. But that is certainly not the case: this book offers a method of inter-
preting mammograms that older practitioners may never have learned, having received their training long before
the advent of "evidence-based medicine", back when this approach was still in its infancy.
x
This book is a valuable learning tool and is of course primarily aimed at the younger, less experienced practitioner.
There is therefore really no need to recommend to such that they read it, as the humble learner will undoubtedly
jump at the chance to enrich his or her education with such a store of valuable knowledge.
However, I do recommend that senior practitioners like myself who are already familiar with mammograms, and
may indeed have even contributed to the birth and development of diagnostic senology, consult this book with the
attention it deserves. It will help them learn the difference between culture and erudition, between presumption
and knowledge.

Cosimo di Maggio
Professor of Radiology, University of Padova

XI
PREFACE

The terminology currently used in mammography is by no means uniform and clear-cut, and may frequently even be
inappropriate for describing mammographic findings from a semiological and semantic point of view. Moreover, the
natural evolution of language has added to the confusion. In view of the extensive use of mammography and the in-
numerable exams performed every day, mostly on asymptomatic individuals, there is an urgent need to standardize the
language used to describe elementary mammographic abnormalities.
There have already been attempts to adopt a common, standardized, appropriate terminology to describe mammogra-
phic findings and establish a logical link between their diagnostic meaning, and clinical recommendations for the patient
in order to suggest the proper action to be taken.
The American College of Radiology BI-RADS® (Breast Imaging Reporting and Data System) is the first example of a
system adopted by a scientific society nationwide, followed by ANAES (Agence Nationale d'Accreditation et d'Eva-
luation de la Sante). The terminology proposed in this volume aims to identify simple, logical and intuitive morpholo-
gical mammographic categories and their main features, to help define and interpret the different findings more easily
for diagnostic assessment along a coherent path that leads to the clinical recommendations directing the patient towards
the most appropriate decision and treatment. Every effort has been made to ensure the language used here is in line
with accepted international terminology. Of course there is bound to be some overlap between categories of signs that
have similar characteristics. It will be up to the individual radiologist to choose the appropriate terms on a case-by-ca-
se basis.
The adoption and dissemination of a common language is a cultural and professional necessity for the individual ra-
diologist, as well as a conditio sine qua non for the successful fulfillment of everyday duties and the ability to share ex-
periences with others.
The images in this atlas were chosen on the basis of the quality of the original documents: only those best illustrating
the various anatomical situations and mammographic categories were selected, to permit a ready understanding and ex-
haustive analysis of the various characteristic signs and findings. The artwork and page layouts, often deliberately repe-
titive in respect of both texts and images, are designed to encourage the radiologist to follow an "automatic" process
starting with perception and leading through analysis to the final diagnosis.
The majority of the mammograms are set out with the lelthand image showing the almost exact dimensions of the breast
- as they usually appear in the radiologist's routine work, and the righthand page depicting details or magnification
views that guide the radiologist towards the final evaluation.

XIII
 PART 1

MAMMOGRAPHY: TERMINOLOGY
 NORMAL

THE NORMAL BREAST

To correctly approach and interpret breast pathologies! it is essential to understand the normal anatomy. Although this con-
cept obviously applies to all organs! it is particularly relevant to the breast! where there is such extensive morphological
and functional variability; the radiological image reflects the degree to which the radiation is absorbed by the different
anatomical structures and their different quantitative proportions and spatial arrangement.
The tissues primarily appearing in a mammogram are fibrous-connective and adipose tissue end, to a lesser extent! ductal
epithelium. The density of the fibroglandular and stromal architecture end, consequently; the overall radiological appear-
ance is related to the degree of hydration of the connective tissue! determined by hormonal stimuli. It is therefore impos-
sible to establish a single! unique "standard" normal radiological anatomy. It is! however; possible to agree that there are
many different patterns of normal anatomy; depending on the individual fibroglandular tissue! and that the same individual
may present physiological and functional variations within the range of normality.
When there are no patent signs of focal or diffuse lesions! the radiologist can inform the patient that her exam is "normaI"!
implying that there is a normal pattern of different mammary structure types detected at mammography. This allays anxiety
caused by the possibility of disease! and enables the patient to avoid further unnecessary exams and useless follow-up.

3
 NORMAL

Radiological anatomy of the breast

Schematically, the radiological examination may show the following normal anatomical structures:
• skin
• nipple and areola
• fatty tissue
• the breast tissue proper, or corpus mammae
• blood vessels

Skin
The skin appears as a thin, continuous, radiopaque rim homogeneous in density, approximately 1 mm thick and readily visible against the radiolu-
cency of the underlying subcutaneous premammary fatty tissue. If the breast is very dense because of the higher density of the underlying parenchy-
mal structure, however, the skin may occasionally not show up clearly even on a correctly exposed mammogram.

Nipple and areola

The skin surrounding the nipple - the areola - can be up to 3-5 mm thick, with a central opacity, roughly cylindrical in shape and of variable
size and density, corresponding to the nipple. Posteriorly there is a generally triangular, heterogeneous trabecular area, the retroareolar region,
which is of particular interest on account of the difficulty of detecting any focal abnormalities that may be there.
Under normal conditions, the lactiferous ducts and sinuses are not seen. If they are enlarged they resemble ribbon-like opacities of varying thick-
ness, running in parallel or divergent lines.

Fatty tissue
Varying amounts of fatty tissue may be present, forming anything from a thin subcutaneous layer to "islets" of various sizes that may occupy
the whole breast, depending on the characteristics and age of the individual woman.
The parenchymal cone is surrounded by fatty tissue which constitutes the pre mammary fat anteriorly and the retromammary fat posteriorly. An-
teriorly, subcutaneous fat appears as a radiolucent layer of variable thickness, traversed by planar sheets of fibrous tissue, the crests of Duret,
which accommodate Cooper's ligaments. The superficial extensions of Cooper's ligaments come to peaks attached to the skin, which anchor the
body of the breast to the subcutaneous tissues, known as retinacula cutis.
Posteriorly, adipose tissue outlines the retromammary space (the bursa of Chassaignac), which separates the breast from the prepectoral fascia
overlying the pectoralis major muscle.

4
NORMAL

5
 NORMAL

Breast tissue proper, or corpus mammae

The body of the mammary gland is roughly cone-shaped with the floor resting on the chest wall and the tip projecting towards the nipple. The shape and
density of breast structures vary from individual to individual, and are influenced by specific sensitivity to hormonal stimuli, which affect relations between
the various tissue components and hence the morphology of the breast.
The concept of mammographic "density" as being strictly related to advancing age is obsolete, so adipose tissue is not synonymous with a senile breast,
and, similarly, the so-called "dense breast" is not necessarily a young breast. Nor is it possible to establish a link, in terms of pathogenesis and symptoms,
between breasts that are patchy and dense at mammography and conditions such as dysplasia or fibrocystic breast disease. These terms have given rise to
much confusion among clinicians and radiologists; not only are they well and truly outdated but they are in fact inappropriate with modern radiology, since
they belong to the realm of pathology.
The variety in the mammographic appearance of the "individual" types of mammary structures is in all likelihood related to differences in the normal process-
es of development and involution, more than to pathological conditions.
For teaching purposes, it may be useful to classify mammographic structures into six main groups reflecting the most frequently encountered breast tissue
patterns, as shown on the opposite page.

Pectoralis muscle
The pectoralis muscle is homogeneously radiopaque; it is located in front of the chest wall and is shaped like an upside-down triangle in the lateral and
mediolateral oblique views. In the craniocaudal view it is crescent-shaped and variably visible depending on the anatomy of the chest and the position and
compression of the breast. In a very small proportion of cases (1 %) one can see medially a small triangular or flame-shaped portion of muscle adjacent to
the sternum, which must not be misinterpreted as a mass.
Generally, a correctly executed mediolateral oblique projection shows the lower margin of the pectoralis muscle following an imaginary line that runs an-
teriorly through the nipple.

Blood vessels
Vessels are more readily visible in breasts that contain plentiful fatty tissue, and appear as thin ribbon-like opacities that may be more or less tortuous; ves-
sel walls may be calcified, in which case they give typical "railwayline" images. In the early stages of calcification, only scattered elongated "casts" are seen,
in a linear pattern, reflecting partial, fragmentary calcification of the vascular wall.

6
 NORMAL

Normal breast tissue patterns visible at mammography

7
 NORMAL

Fibroadipose structure Fibroglandular structure

Total absence of fibroglandular tissue. Only traces of the stromal network may remain. Typical triangular fibroglandular configuration, clearly showing the tip of the triangle in
the retroareolar region and the perimammary fatty spaces. The parenchymal compo-
nent is prevalently planar in appearance, or slightly nodular. The texture of the stroma
is readily recognized, with the crests of Duret outlining the adipose areas between the
8 retinacula cutis.