MammographyMammography

A mammogram is an A mammogram is an x-rayx-ray picture of the picture of the breasts. It is used to find tumors and to help breasts. It is used to find tumors and to help tell the difference between non-cancerous tell the difference between non-cancerous (benign) and cancerous (malignant) (benign) and cancerous (malignant) disease.disease.

Mammography uses low dose x-ray; high Mammography uses low dose x-ray; high contrast, high-resolution film; and an x-ray contrast, high-resolution film; and an x-ray system designed specifically for imaging the system designed specifically for imaging the breasts. breasts.

Early detection of breast cancers. Early detection of breast cancers.

To help the radiologist or surgeon guide the To help the radiologist or surgeon guide the needle to the correct area in the breast needle to the correct area in the breast during biopsy. during biopsy.

AnatomyAnatomy The breast is a mass of glandular, fatty, and The breast is a mass of glandular, fatty, and

fibrous tissues positioned over the pectoral fibrous tissues positioned over the pectoral muscles of the chest wall and attached to muscles of the chest wall and attached to the chest wall by fibrous strands called the chest wall by fibrous strands called Cooper’s ligaments. A layer of fatty tissue Cooper’s ligaments. A layer of fatty tissue surrounds the breast glands and extends surrounds the breast glands and extends throughout the breast. The fatty tissue gives throughout the breast. The fatty tissue gives the breast a soft consistency. the breast a soft consistency.

The breast is composed of:The breast is composed of: milk glands (lobules) that produce milk milk glands (lobules) that produce milk ducts that transport milk from the milk ducts that transport milk from the milk

glands (lobules) to the nipple glands (lobules) to the nipple nipple nipple areola (pink or brown pigmented region areola (pink or brown pigmented region

surrounding the nipple) surrounding the nipple) connective (fibrous) tissue that surrounds connective (fibrous) tissue that surrounds

the lobules and ducts the lobules and ducts fat fat

– Breast profile:Breast profile:

AA ducts ducts BB lobules lobules CC dilated section of duct to dilated section of duct to

hold milkhold milk DD nipple nipple EE fat fat FF pectoralis major muscle pectoralis major muscle GG chest wall/rib cage chest wall/rib cage

Schematic Diagram of the Female Schematic Diagram of the Female Breast Breast

                                   

Basic Physics of Mammography:Basic Physics of Mammography: X-ray images depend on differences in x-ray stopping X-ray images depend on differences in x-ray stopping

power (attenuation) to separate tissues. In general, a clear power (attenuation) to separate tissues. In general, a clear separation between normal functioning tissue, and separation between normal functioning tissue, and abnormal cancerous tissues is not possible since their abnormal cancerous tissues is not possible since their attenuation if very similar. However both functional tissue attenuation if very similar. However both functional tissue and cancer can be separated from fatty storage tissues and cancer can be separated from fatty storage tissues which normally surround active breast tissue, even in lean which normally surround active breast tissue, even in lean persons. This is due to a substantially lower attenuation persons. This is due to a substantially lower attenuation caused by fat. caused by fat.

In older women, the functional glandular tissue diminishes, In older women, the functional glandular tissue diminishes, leaving only thin supporting tissues clearly outlined by fatty leaving only thin supporting tissues clearly outlined by fatty tissues. Mammography in these "mature" breasts is very tissues. Mammography in these "mature" breasts is very effective, since even small cancers are well outlined by fat. effective, since even small cancers are well outlined by fat. In addition, many cancers develop calcium deposits which In addition, many cancers develop calcium deposits which strongly stop X-rays and are easily seen on mammograms. strongly stop X-rays and are easily seen on mammograms.

Basic Limitations of Basic Limitations of Mammography:Mammography:

Since mammography cannot separate Since mammography cannot separate normal gland tissue from tumors, it is much normal gland tissue from tumors, it is much more effective when gland tissue diminishes more effective when gland tissue diminishes with age. Many women retain glandular with age. Many women retain glandular tissue as they "mature", and it camouflages tissue as they "mature", and it camouflages tumors until they are large. As you might tumors until they are large. As you might expect, the young women's breast normally expect, the young women's breast normally contains more active tissue, which again contains more active tissue, which again interferes with detection of small cancers. interferes with detection of small cancers.

Types of Mammography Types of Mammography

Screening Screening

DiagnosticDiagnostic

Ductgram/Galactogram (imaging the breast Ductgram/Galactogram (imaging the breast ducts) ducts)

Screening mammographyScreening mammography Screening mammographyScreening mammography is an x-ray examination is an x-ray examination

of the breasts in a woman who is of the breasts in a woman who is asymptomaticasymptomatic (has no complaints or symptoms of breast cancer). (has no complaints or symptoms of breast cancer). The goal of screening mammography is to detect The goal of screening mammography is to detect cancer when it is still too small to be felt by a cancer when it is still too small to be felt by a woman or her physician. Early detection of small woman or her physician. Early detection of small breast cancers by screening mammography breast cancers by screening mammography greatly improves a woman's chances for greatly improves a woman's chances for successful treatment. successful treatment. Screening mammography is Screening mammography is recommended every one to two years for women recommended every one to two years for women once they reach 40 years of age and every year once they reach 40 years of age and every year once they reach 50 years of ageonce they reach 50 years of age. In some . In some instances, physicians may recommend beginning instances, physicians may recommend beginning screening mammography before age 40 (i.e. if the screening mammography before age 40 (i.e. if the woman has a strong family history of breast woman has a strong family history of breast cancer). cancer).

Diagnostic mammographyDiagnostic mammography Diagnostic mammographyDiagnostic mammography is an x-ray examination is an x-ray examination

of the breast in a woman who either has a breast of the breast in a woman who either has a breast complaint (for example, a breast lump or nipple complaint (for example, a breast lump or nipple discharge is found during self-exam) or has had discharge is found during self-exam) or has had an abnormality found during screening an abnormality found during screening mammography. It is more involved and time-mammography. It is more involved and time-consuming than screening mammography and is consuming than screening mammography and is used to determine exact size and location of used to determine exact size and location of breast abnormalities and to image the surrounding breast abnormalities and to image the surrounding tissue and lymph nodes. Typically, several tissue and lymph nodes. Typically, several additional views of the breast are imaged and additional views of the breast are imaged and interpreted during diagnostic mammography. interpreted during diagnostic mammography. Thus, diagnostic mammography is more Thus, diagnostic mammography is more expensive than screening mammography. expensive than screening mammography.

Mammography equipment Mammography equipment

How is Mammography How is Mammography Performed?Performed?

During mammography, the technologist will During mammography, the technologist will position the patient and image each breast position the patient and image each breast separately. One at a time, each breast is separately. One at a time, each breast is carefully positioned on a special film carefully positioned on a special film cassette and then gently compressed with a cassette and then gently compressed with a paddle (often made of clear Plexiglas or paddle (often made of clear Plexiglas or other plastic). This compression flattens the other plastic). This compression flattens the breast so that the maximum amount of breast so that the maximum amount of tissue can be imaged and examined. tissue can be imaged and examined.

Cont…Cont… At some facilities, mammography technologists At some facilities, mammography technologists

may place adhesive markers to the breast skin may place adhesive markers to the breast skin prior to taking images of the breast. The purpose prior to taking images of the breast. The purpose of the adhesive markers is twofold: of the adhesive markers is twofold: firstfirst,, to identify to identify areas with moles, blemishes or scars so that they areas with moles, blemishes or scars so that they are not mistaken for abnormalities, and are not mistaken for abnormalities, and secondly,secondly, to identify areas that may be of concern (e.g. a to identify areas that may be of concern (e.g. a lump was felt during physical examination). Some lump was felt during physical examination). Some centers routinely mark the nipple with a small dot centers routinely mark the nipple with a small dot to provide a clear "landmark" for the radiologist on to provide a clear "landmark" for the radiologist on the mammogram images. the mammogram images.

Breast compression is necessary in Breast compression is necessary in order to:order to:

Even out the breast thickness so that all of the Even out the breast thickness so that all of the tissue can be visualized. tissue can be visualized.

Spread out the tissue so that small abnormalities Spread out the tissue so that small abnormalities are less likely to be obscured by overlying breast are less likely to be obscured by overlying breast tissue. tissue.

Allow the use of a lower x-ray dose since a thinner Allow the use of a lower x-ray dose since a thinner amount of breast tissue is being imaged. amount of breast tissue is being imaged.

Hold the breast still in order to minimize blurring of Hold the breast still in order to minimize blurring of the image caused by motion. the image caused by motion.

Reduce x-ray scatter to increase sharpness of Reduce x-ray scatter to increase sharpness of picture. picture.

Mammo app of normal breastMammo app of normal breast Different tissues in the breast absorb Different tissues in the breast absorb

different amounts of x-rays, producing different amounts of x-rays, producing different shades of black, gray, and white on different shades of black, gray, and white on the film: the film:

Fatty tissue absorbs a small amount of x-Fatty tissue absorbs a small amount of x-rays and appears black or dark gray. rays and appears black or dark gray.

Normal fibrous and glandular tissues (milk Normal fibrous and glandular tissues (milk glands, lymph nodes) contain water fluid glands, lymph nodes) contain water fluid and absorb a moderate amount of x-rays, and absorb a moderate amount of x-rays, and appear light gray. and appear light gray.

Fibrous and glandular tissues may contain Fibrous and glandular tissues may contain calcium and appear nearly white or white. calcium and appear nearly white or white.

Breast comp & mammo app..Breast comp & mammo app..

Mammographic viewsMammographic views

Standard viewsStandard views

Supplemental viewsSupplemental views

Standard viewsStandard views

CC (cranio-caudal) viewCC (cranio-caudal) view

MLO (medio-lateral oblique) viewMLO (medio-lateral oblique) view

Supplemental ViewsSupplemental Views

Lateromedial, LM: Lateromedial, LM: Mediolateral view, ML Mediolateral view, ML Exaggerated cranial-caudal,Exaggerated cranial-caudal, Magnification views, Spot compression viewSpot compression view

Mammographic viewsMammographic views

Mediolateral Oblique View (MLO) Mediolateral Oblique View (MLO) The mediolateral oblique view (MLO) is The mediolateral oblique view (MLO) is

taken from an oblique or angled view. taken from an oblique or angled view. During routine screening mammography, During routine screening mammography, the MLO view is preferred over a lateral 90-the MLO view is preferred over a lateral 90-degree projection because more of the degree projection because more of the breast tissue can be imaged in the upper breast tissue can be imaged in the upper outer quadrant of the breast and the axilla outer quadrant of the breast and the axilla (armpit).(armpit).

With the MLO view, the pectoral (chest) With the MLO view, the pectoral (chest) muscle should be depicted obliquely from muscle should be depicted obliquely from above and visible down to the level of the above and visible down to the level of the nipple or further down. The shape of the nipple or further down. The shape of the muscle should curve or bulge outward as a muscle should curve or bulge outward as a sign that the muscle is relaxed; the medial sign that the muscle is relaxed; the medial (middle) portion of the breast should be (middle) portion of the breast should be prominent in the MLO view. It is important prominent in the MLO view. It is important that compression be applied over the whole that compression be applied over the whole image area. The nipple should be depicted image area. The nipple should be depicted in profile and a small stomach fold should be in profile and a small stomach fold should be visible as a sign that the whole breast is visible as a sign that the whole breast is reproduced. reproduced.

Cranio-Caudal View (CC)Cranio-Caudal View (CC) The cranio-caudal view (CC) images the The cranio-caudal view (CC) images the

breast from above. This view may be taken breast from above. This view may be taken during routine screening mammography and during routine screening mammography and during diagnostic mammography.during diagnostic mammography.

With the CC view, the entire breast With the CC view, the entire breast parenchyma (glandular tissue) should be parenchyma (glandular tissue) should be depicted. The fatty tissue closest to the depicted. The fatty tissue closest to the breast muscle should appear as a dark strip breast muscle should appear as a dark strip on the x-ray and behind that it should be on the x-ray and behind that it should be possible to make out the pectoral (chest) possible to make out the pectoral (chest) muscle. The nipple should be depicted in muscle. The nipple should be depicted in profile. profile.

Medio-Lateral View (ML)Medio-Lateral View (ML) The medio-lateral view (ML) is taken from the The medio-lateral view (ML) is taken from the

center of the chest outward. If no oblique center of the chest outward. If no oblique projection is taken, the mediolateral position may projection is taken, the mediolateral position may be preferable to the latero-medial view (LM, be preferable to the latero-medial view (LM, images the breast from the outer side of the breast images the breast from the outer side of the breast inward toward the center of the chest) since the inward toward the center of the chest) since the lateral side of the breast, where pathological lateral side of the breast, where pathological changes are most commonly found, is then closest changes are most commonly found, is then closest to the film. However, if the physician wants to to the film. However, if the physician wants to include as much of the medial side of the breast include as much of the medial side of the breast as possible, the LM view may be chosen.as possible, the LM view may be chosen.

With a lateral view, the pectoral (chest) With a lateral view, the pectoral (chest) muscle should be depicted as a narrow light muscle should be depicted as a narrow light band on at least half of the picture. The band on at least half of the picture. The nipple should be depicted in profile and a nipple should be depicted in profile and a clear stomach fold should be visible under clear stomach fold should be visible under the breast.the breast.

Latero-Medial View (LM)Latero-Medial View (LM)

The latero-medial view (LM) images the The latero-medial view (LM) images the breast from its outer side toward the center breast from its outer side toward the center of the chest. When physicians want to of the chest. When physicians want to include as much of the medial portion of the include as much of the medial portion of the breast, the LM view may be used.breast, the LM view may be used.

Spot compressionSpot compression viewview also known as also known as compression mammogram, compression mammogram,

spot view, cone views, or focal spot view, cone views, or focal compression viewscompression views. All mammograms . All mammograms involve compression of the breast. Spot involve compression of the breast. Spot views apply the compression to a smaller views apply the compression to a smaller area of tissue using a small compression area of tissue using a small compression plate or cone. By applying compression to plate or cone. By applying compression to only a specific area of the breast, the only a specific area of the breast, the effective pressure is increased on that spot. effective pressure is increased on that spot. This results in better tissue separation and This results in better tissue separation and allows better visualization of the small area allows better visualization of the small area in question. in question.

Spot compressionSpot compression view cont…view cont… Spot compression views show the borders Spot compression views show the borders

of an abnormality or questionable area of an abnormality or questionable area better than the standard mammography better than the standard mammography views. Some areas that look unusual on the views. Some areas that look unusual on the standard mammography images are often standard mammography images are often shown to be normal tissue on the spot shown to be normal tissue on the spot views. True abnormalities usually appear views. True abnormalities usually appear more prominently and the margins (borders) more prominently and the margins (borders) of the abnormality can be better seen on of the abnormality can be better seen on compression views.compression views.

Magnification viewsMagnification views use a small magnification table which brings use a small magnification table which brings

the breast closer to the x-ray source and the breast closer to the x-ray source and further away from the film plate. This allows further away from the film plate. This allows the acquisition of "zoomed in" images (2 the acquisition of "zoomed in" images (2 times magnification) of the region of interest. times magnification) of the region of interest. Magnification views provide a clearer Magnification views provide a clearer assessment of the borders and the tissue assessment of the borders and the tissue structures of a suspicious area, non structures of a suspicious area, non palpable lesion or a mass. Magnification palpable lesion or a mass. Magnification views are often used to evaluate micro-views are often used to evaluate micro-calcifications, tiny specks of calcium in the calcifications, tiny specks of calcium in the breast that may indicate a small cancer .breast that may indicate a small cancer .

Magnification views cont..Magnification views cont.. Before performing a magnification view, the Before performing a magnification view, the

mammographer must attach a firm, radiolucent mammographer must attach a firm, radiolucent platform to the unit. This device allows the breast platform to the unit. This device allows the breast to be elevated from the film, resulting in an to be elevated from the film, resulting in an increased object-to-image distance (OID). The increased object-to-image distance (OID). The platform may vary in height, depending on how platform may vary in height, depending on how much the radiologist has chosen to magnify the much the radiologist has chosen to magnify the suspicious area. In addition, the standard suspicious area. In addition, the standard compression device is removed from the compression device is removed from the mammography unit and replaced with a modified mammography unit and replaced with a modified compression paddle designed especially for compression paddle designed especially for magnification views.magnification views.

Magnification views cont..Magnification views cont.. Peak kilovoltage (kVp) is one factor that Peak kilovoltage (kVp) is one factor that

must be considered. In elevating the breast, must be considered. In elevating the breast, a gap is produced between the breast and a gap is produced between the breast and the film. The space created reduces the the film. The space created reduces the amount of scatter reaching the film, a amount of scatter reaching the film, a condition known as the air-gap effect. As a condition known as the air-gap effect. As a result, a portion of radiographic density is result, a portion of radiographic density is lost, and the kVp must be increased lost, and the kVp must be increased accordingly to maintain an adequate accordingly to maintain an adequate exposure.exposure.

Magnification views cont..Magnification views cont..

In addition to magnifying the object, In addition to magnifying the object, increasing OID also decreases geometric increasing OID also decreases geometric sharpness. To correct this problem, a sharpness. To correct this problem, a smaller focal spot must be used. During smaller focal spot must be used. During routine mammography, a .3 mm focal spot is routine mammography, a .3 mm focal spot is standard. During magnification standard. During magnification mammography, however, a .1 mm focal spot mammography, however, a .1 mm focal spot is necessary to decrease the blurring that is necessary to decrease the blurring that results from image enlargement as well as results from image enlargement as well as to increase recorded detail. to increase recorded detail.

POSITIONING THE MAMMOGRAM POSITIONING THE MAMMOGRAM FOR VIEWINGFOR VIEWING

When viewing a mammogram it is important When viewing a mammogram it is important to know the exact orientation of the image. to know the exact orientation of the image. The breasts are best viewed as symmetric The breasts are best viewed as symmetric organs.  Comparison of the right breast to organs.  Comparison of the right breast to the left breast is done for evaluation of the left breast is done for evaluation of symmetry.  The conventional method is to symmetry.  The conventional method is to evaluate mammograms in a mirror-like evaluate mammograms in a mirror-like fashion with fashion with both the MLO and CC views both the MLO and CC views mounted back to back. mounted back to back.     

Some radiologists mount the right Some radiologists mount the right mammogram on the right and the left one on mammogram on the right and the left one on the left.  Others prefer to the left.  Others prefer to view the view the mammograms as if they were facing the mammograms as if they were facing the patient with the left breast on the observer's patient with the left breast on the observer's right and the right breast on the observer's right and the right breast on the observer's left.   left.  

There are no hard-fast rules, and positioning There are no hard-fast rules, and positioning of mammograms on a viewbox is a matter of of mammograms on a viewbox is a matter of individual preference.  Nonetheless, one's individual preference.  Nonetheless, one's approach should be systematic to avoid approach should be systematic to avoid mistakes.  mistakes. 

Viewing the mammogram should proceed from a Viewing the mammogram should proceed from a distance to closer scrutiny of the particular distance to closer scrutiny of the particular suspicious areas.  From a distance, the images suspicious areas.  From a distance, the images should be compared area for area, and the should be compared area for area, and the respective regions of the left and right breasts respective regions of the left and right breasts should look similar.  One should have both images should look similar.  One should have both images in view whereby the contour of the breast, the size in view whereby the contour of the breast, the size of the breast, and its symmetric density could be of the breast, and its symmetric density could be evaluated.  This bird's eye evaluation for symmetry evaluated.  This bird's eye evaluation for symmetry is followed by a close-up individual view of each is followed by a close-up individual view of each image, looking for disruption in the "normal image, looking for disruption in the "normal pattern" of the breast such as abnormal densities, pattern" of the breast such as abnormal densities, areas of architectural distortion, masses and areas of architectural distortion, masses and calcifications.  calcifications. 

A magnifying lens may aid the viewer in his or her A magnifying lens may aid the viewer in his or her search for suspected small masses and search for suspected small masses and

microcalcifications or to clarify a small detail.microcalcifications or to clarify a small detail.

In some cases, a magnified mammographic view In some cases, a magnified mammographic view can be taken to clarify the characteristics of a can be taken to clarify the characteristics of a

suspected lesion.suspected lesion.

If there are prior mammograms available for If there are prior mammograms available for review, the individual breasts are evaluated review, the individual breasts are evaluated for changes over time.  The goal here is to for changes over time.  The goal here is to look for potential changes in asymmetric look for potential changes in asymmetric density as well as to evaluate development density as well as to evaluate development of new masses (neodensities) or new of new masses (neodensities) or new calcifications. However, if the present study calcifications. However, if the present study is unremarkable, prior mammograms are of is unremarkable, prior mammograms are of lesser importance.lesser importance.

DEFINITION OF MAMMOGRAPHIC DEFINITION OF MAMMOGRAPHIC LESIONSLESIONS

The sensitivity of mammography is initially determined by The sensitivity of mammography is initially determined by the relative background composition of the breast the relative background composition of the breast parenchyma. The denser the breast the less sensitive it is parenchyma. The denser the breast the less sensitive it is to the detection of small masses, although small to the detection of small masses, although small calcifications can generally still be detected. calcifications can generally still be detected.

The mammograms are initially evaluated for the presence The mammograms are initially evaluated for the presence of of masses, masses, architectural distortion, architectural distortion, asymmetric parenchyma,asymmetric parenchyma, calcifications andcalcifications and skin changesskin changes These mammographic findings are then further characterized and These mammographic findings are then further characterized and

compared to old studies, if available. compared to old studies, if available.

Mammographicaly aMammographicaly amassmass is defined as a space occupying is defined as a space occupying lesion seen in two different projections, withlesion seen in two different projections, with

densitydensity defined as a collection seen in only defined as a collection seen in only one view.one view.

A mass is then further characterized by it’s A mass is then further characterized by it’s shape, margins, density, size, orientationshape, margins, density, size, orientation and presence of and presence of associated calcificationsassociated calcifications. .

Shape Shape is a generally nonspecific characteristic, is a generally nonspecific characteristic, both benign and malignant masses tend to both benign and malignant masses tend to develop in one spot and grow develop in one spot and grow circumferentially. An irregular shape is more circumferentially. An irregular shape is more concerning as its suggests indistinct or concerning as its suggests indistinct or irregular margins. Some skins lesions, warts irregular margins. Some skins lesions, warts and seborreic keratoses, have typical and seborreic keratoses, have typical appearances due to the variegated surfaces appearances due to the variegated surfaces and occasionally radiolucent/air halo. Some and occasionally radiolucent/air halo. Some intramammary nodes have a typical reniform intramammary nodes have a typical reniform configuration with a fatty notch. configuration with a fatty notch.

Margin or contour analysisMargin or contour analysis

characterizes the transition zone from mass characterizes the transition zone from mass to surrounding parenchyma or fatty tissue. to surrounding parenchyma or fatty tissue. The significance arises from the tendency of The significance arises from the tendency of invasive carcinoma to infiltrate adjacent invasive carcinoma to infiltrate adjacent tissue and have indistinct, microlobulated or tissue and have indistinct, microlobulated or frankly spiculated margins. frankly spiculated margins.

Well circumscribed or sharply Well circumscribed or sharply marginated massesmarginated masses, , either with or without either with or without a radiolucent halo, are probably benign. If all a radiolucent halo, are probably benign. If all margins remain sharply circumscribed on margins remain sharply circumscribed on magnification views , and there is no associated magnification views , and there is no associated suspicious calcification, 98% to 99% will be benign suspicious calcification, 98% to 99% will be benign with a differential of fibroadenoma, cyst or with a differential of fibroadenoma, cyst or intramammary lumph node. When initially found intramammary lumph node. When initially found ultrasound to exclude a cyst is a very useful ultrasound to exclude a cyst is a very useful adjuvant study. If the lesion is solid on ultrasound, adjuvant study. If the lesion is solid on ultrasound, serial six month mammograms for two years would serial six month mammograms for two years would be suggested, because of the low, 1-2%, be suggested, because of the low, 1-2%, incidence of malignancy. An alternative to serial incidence of malignancy. An alternative to serial imaging would be FNA or core needle biopsy. imaging would be FNA or core needle biopsy.

Circumscribed masses with irregular or Circumscribed masses with irregular or microlobulated marginsmicrolobulated margins on magnification on magnification views should be considered suspicious and views should be considered suspicious and biopsy suggested.biopsy suggested.

Similarly if the margins remain indistinct or Similarly if the margins remain indistinct or ill-defined on additional special views the ill-defined on additional special views the lesion must be considered suspicious and lesion must be considered suspicious and biopsy considered. biopsy considered.

Masses with spiculated margins Masses with spiculated margins are suggestive of malignancyare suggestive of malignancy

With cancer, the spicules represent finger-With cancer, the spicules represent finger-like projections of the malignant cells. Other like projections of the malignant cells. Other spiculated densities may represent radial spiculated densities may represent radial scar/sclerosising adenosis but are still scar/sclerosising adenosis but are still suspicious and can be associated with suspicious and can be associated with tubular carcinoma. A spiculated density may tubular carcinoma. A spiculated density may also be secondary to a post operative scar, also be secondary to a post operative scar, although the clinical history should provide although the clinical history should provide the clue and subsequent serial follow up the clue and subsequent serial follow up should demonstrate maturation and should demonstrate maturation and involution or at least stability of the scar. involution or at least stability of the scar.

Obscured MarginsObscured Margins (indeterminate, need further views): In this case, a (indeterminate, need further views): In this case, a

part of a mass is seen, part of the mass has a part of a mass is seen, part of the mass has a circumscribed margin, but some or perhaps most circumscribed margin, but some or perhaps most of the margin is covered by overlying tissue, of the margin is covered by overlying tissue, creating an indistinct margin. In this case, is is creating an indistinct margin. In this case, is is frequently possible to move the extraneous tissue frequently possible to move the extraneous tissue using special views (focal compression view, using special views (focal compression view, tissue roll view), which allow a completely tissue roll view), which allow a completely circumscribed (probable benign-watchful waiting) circumscribed (probable benign-watchful waiting) margin to be seen. If a complete circumscribed margin to be seen. If a complete circumscribed margin cannot be found, the mass must be margin cannot be found, the mass must be considered suspicious (consider biopsy) considered suspicious (consider biopsy)

MarginsMargins The margin is the border of a mass, and it should The margin is the border of a mass, and it should

be examined carefully, sometimes using be examined carefully, sometimes using magnification view for clarity. It is one of the most magnification view for clarity. It is one of the most important criteria in determining whether the mass important criteria in determining whether the mass is likely to be benign or malignant. There are is likely to be benign or malignant. There are five five type of marginstype of margins as defined by as defined by BIRADS:BIRADS:

Circumscribed,Circumscribed, Obscured, Obscured, Micro-lobulated, Micro-lobulated, Ill-defined, and Ill-defined, and Spiculated. Spiculated.

Circumscribed marginsCircumscribed margins are well defined and are well defined and sharply demarcated with an abrupt transition sharply demarcated with an abrupt transition between the lesion and the surrounding tissue. between the lesion and the surrounding tissue.

Microlobulated marginsMicrolobulated margins have small have small undulating circles along the edge of the undulating circles along the edge of the mass.mass.

Obscured marginsObscured margins are hidden by are hidden by superimposed or adjacent normal tissue.superimposed or adjacent normal tissue.

Ill-defined marginsIll-defined margins are poorly defined and are poorly defined and scattered. scattered.

Spiculated marginsSpiculated margins are marked by are marked by radiating thin lines. If there is no visible radiating thin lines. If there is no visible mass, the basic description of mass, the basic description of architectural architectural distortiondistortion with spiculation as a modifier is with spiculation as a modifier is used. used.

DensityDensity The density or degree of X-ray attenuation is defined relative The density or degree of X-ray attenuation is defined relative

to the expected attenuation of an equal volume of normal to the expected attenuation of an equal volume of normal glanular tissue of the breast. It is important because most glanular tissue of the breast. It is important because most breast cancers that form a mass appear to have attenuation breast cancers that form a mass appear to have attenuation equal to or greater thatn the surrounding fibroglandular equal to or greater thatn the surrounding fibroglandular tissue. tissue.

CancerCancer shows high density because the cancer is firm and shows high density because the cancer is firm and resists being compressed as thinly as normal tissue, and resists being compressed as thinly as normal tissue, and thus remains thicker and denser than surroundings, even thus remains thicker and denser than surroundings, even with focal compression views. with focal compression views. The tendancy to stand-out is may be helpful in finding the The tendancy to stand-out is may be helpful in finding the tumor in a dense breast. tumor in a dense breast. It is rare (though not impossible) for breast cancers to appear It is rare (though not impossible) for breast cancers to appear as lower density. Breast cancers are never fatty (radiolucent) as lower density. Breast cancers are never fatty (radiolucent) in character, though they may trap fat. Central lucency is a in character, though they may trap fat. Central lucency is a particularly useful sign or benign lymph nodes. particularly useful sign or benign lymph nodes.

The density catagories used are:The density catagories used are:High densityHigh density: clearly higher than surrounding, : clearly higher than surrounding, suspicious.suspicious.Equal densityEqual density: density not appreaciably different, : density not appreaciably different, neutral significance.neutral significance.Low densityLow density: density lower, but not fat containing, : density lower, but not fat containing, neutral significance.neutral significance.

Fat containingFat containing: Radiolucent. This includes all : Radiolucent. This includes all lesions containing fat such as oil cyst, lipoma, lesions containing fat such as oil cyst, lipoma, galactocele, hamartoma or fibrolipoma. This is a galactocele, hamartoma or fibrolipoma. This is a benign finding unless other characteristics are benign finding unless other characteristics are suspicous.suspicous.

  

LocationLocation

The location of the mass may be The location of the mass may be established from the physical examination if established from the physical examination if the mass is palpable. Otherwise, its location the mass is palpable. Otherwise, its location can be determined from several different can be determined from several different mammographic views. It is important to mammographic views. It is important to realize that the mass seen on a realize that the mass seen on a mammogram may not correspond to a mammogram may not correspond to a palpable lump. Because breast cancer tends palpable lump. Because breast cancer tends to develop in the peripheral zone of the to develop in the peripheral zone of the breast's parenchymal cone, a mass' location breast's parenchymal cone, a mass' location can raise suspicion of malignancy. can raise suspicion of malignancy.

SizeSize

Size alone does not predict malignancy. Size alone does not predict malignancy. Nonetheless, the size of a malignant mass Nonetheless, the size of a malignant mass is indicative of its progression. The objective is indicative of its progression. The objective of mammography is to detect breast cancer of mammography is to detect breast cancer in its earliest stage of development. in its earliest stage of development.

Architectural DistortionArchitectural Distortion Architectural distortion per se is not a mass. In this Architectural distortion per se is not a mass. In this

class, the normal outline of tissues is distorted, class, the normal outline of tissues is distorted, sometimes with no definable mass. It includes sometimes with no definable mass. It includes spiculations (lines radiating from a center), spiculations (lines radiating from a center), retraction (puckering) of normal connective tissue retraction (puckering) of normal connective tissue lines. lines. It is a desmoplastic reaction in which there is focal It is a desmoplastic reaction in which there is focal disruption of the normal breast tissue pattern. disruption of the normal breast tissue pattern. Radiographically it appears as a distortion in which Radiographically it appears as a distortion in which surrounding breast tissues appear to be "pulled surrounding breast tissues appear to be "pulled inward" into a focal point. Often, it can be best inward" into a focal point. Often, it can be best perceived at the interface between breast perceived at the interface between breast parenchyma and subcutaneous and parenchyma and subcutaneous and retromammary fat. retromammary fat.

Architectural distortion can also appear within the Architectural distortion can also appear within the breast parenchyma itself, in which case it may be breast parenchyma itself, in which case it may be best appreciated from a distance.best appreciated from a distance.

It is important to do as many special view as It is important to do as many special view as needed to establish the finding, as unexplained needed to establish the finding, as unexplained architectural distortion usually merits biopsy even architectural distortion usually merits biopsy even when no mass is evident. when no mass is evident.

While architectural distortion is a localizing sign of While architectural distortion is a localizing sign of cancer, a surgical scar, fibrocystic change, and in cancer, a surgical scar, fibrocystic change, and in some cases, the superimposition of breast tissues some cases, the superimposition of breast tissues may give the same appearance. may give the same appearance.

Benign causes of architectual distortion Benign causes of architectual distortion such as scarring tend to remain unchanged such as scarring tend to remain unchanged or improve, so whenever previous or improve, so whenever previous mammograms have been done, it is most mammograms have been done, it is most important to compare to see if changes have important to compare to see if changes have really occurred. really occurred.

Evaluation of Associated Evaluation of Associated Structural Changes in the breastStructural Changes in the breast

These are changes that may occur alone or more These are changes that may occur alone or more commonly in the tissues surrounding masses or commonly in the tissues surrounding masses or calcifications. Many are suspicious in that they imply a calcifications. Many are suspicious in that they imply a process which is infiltrating and altering the character process which is infiltrating and altering the character of adjacent tissues (1-6). Category 7 - Skin lesion is a of adjacent tissues (1-6). Category 7 - Skin lesion is a benign finding.benign finding.

1.) Skin retraction: The skin appears to be pulled or 1.) Skin retraction: The skin appears to be pulled or tethered into an abnormality. This is a common finding tethered into an abnormality. This is a common finding in more advanced infiltrative cancers, but can also in more advanced infiltrative cancers, but can also occur with scarring due to previous injury or biopsy. In occur with scarring due to previous injury or biopsy. In addition to a careful history to identify any previous addition to a careful history to identify any previous injury, previous mammograms can be very helpful if injury, previous mammograms can be very helpful if they demonstrate the skin retraction is a long standing they demonstrate the skin retraction is a long standing finding due to scarring, and not a recent result of finding due to scarring, and not a recent result of infiltration.infiltration.

2.) Nipple retraction: The nipple is pulled in or 2.) Nipple retraction: The nipple is pulled in or inverted. This can be seen as another sign of inverted. This can be seen as another sign of advanced cancer infiltration, but is also a fairly advanced cancer infiltration, but is also a fairly common observation in otherwise normal patients. common observation in otherwise normal patients. Previous studies documenting stability, and the Previous studies documenting stability, and the lack of an underlying mass are factors which can lack of an underlying mass are factors which can reduce the concern regarding this finding. It is reduce the concern regarding this finding. It is important to exam the underlying area carefully important to exam the underlying area carefully however to look for architectural distortion which however to look for architectural distortion which can indicate a tumor even in the absence of a can indicate a tumor even in the absence of a mass.mass.

3.) Skin thickening: When diffuse this is often 3.) Skin thickening: When diffuse this is often related to other systemic problems. When related to other systemic problems. When localized, it may result from direct infiltration, or localized, it may result from direct infiltration, or tumor blockage of local lymphatic drainage. As tumor blockage of local lymphatic drainage. As with 1 and 2, the absence of change, and the with 1 and 2, the absence of change, and the absence of an associated mass reduce the absence of an associated mass reduce the importance of this finding.importance of this finding.

4.) Trabecular thickening: This is focal thickening 4.) Trabecular thickening: This is focal thickening of fibrous septae in the breast. It raises question of of fibrous septae in the breast. It raises question of infiltration particularly in association with mass.infiltration particularly in association with mass.

  5.) Axillary Adenopathy: Enlarged non-fatty lymph 5.) Axillary Adenopathy: Enlarged non-fatty lymph nodes in the axilla may be commented on. nodes in the axilla may be commented on. Because the enlargement may be due to Because the enlargement may be due to inflammatory involvement in the upper extremity or inflammatory involvement in the upper extremity or breast, attributing enlargement to breast breast, attributing enlargement to breast malignancy is often unreliable.malignancy is often unreliable.

6.) Architectural Distortion: When disturbance in 6.) Architectural Distortion: When disturbance in the course and shape of the normal trebecular the course and shape of the normal trebecular architecture is seen, particularly if it persists with architecture is seen, particularly if it persists with directed focal compression views, the possibility of directed focal compression views, the possibility of infiltration should be entertained. This is a finding infiltration should be entertained. This is a finding in itself if no mass is seen, and is a associated in itself if no mass is seen, and is a associated finding when distorted or retracted tissues are finding when distorted or retracted tissues are seen surrounding a mass or other finding.seen surrounding a mass or other finding.

7.) Skin Lesion: This is a mammographic finding 7.) Skin Lesion: This is a mammographic finding projects from skin over breast in two views. It is projects from skin over breast in two views. It is almost never associated with breast cancer, but almost never associated with breast cancer, but may simulate a mass. Careful positioning with may simulate a mass. Careful positioning with special tangential views are used to prove the special tangential views are used to prove the benign skin location.benign skin location.

diffuse skin thickening diffuse skin thickening

CALCIFICATIONS CALCIFICATIONS Calcifications are often important and common Calcifications are often important and common

findings on a mammogram. They can be produced findings on a mammogram. They can be produced from cell secretion or from necrotic cellular debris. from cell secretion or from necrotic cellular debris. They may be intramammary, within and around They may be intramammary, within and around the ducts, within the lobules, in vascular the ducts, within the lobules, in vascular structures, in interlobular connective tissue or fat. structures, in interlobular connective tissue or fat. Alternatively, they may be found in the skin. They Alternatively, they may be found in the skin. They can appear with or without an associated lesion, can appear with or without an associated lesion, and their morphologies and distribution provide and their morphologies and distribution provide clues as to their etiology as well as whether they clues as to their etiology as well as whether they can be associated with a benign or malignant can be associated with a benign or malignant process. process.

Calcifications found with a mass provide Calcifications found with a mass provide further information about that particular further information about that particular mass. For example, an involuting mass. For example, an involuting fibroadenoma will often contain popcorn-like fibroadenoma will often contain popcorn-like macrocalcifications. Similarly, fine macrocalcifications. Similarly, fine curvilinear calcifications at the margin (i.e. curvilinear calcifications at the margin (i.e. rim calcifications) of a round or oval mass rim calcifications) of a round or oval mass indicate a benign process. On the other indicate a benign process. On the other hand, a mass with pleomorphic, irregularly hand, a mass with pleomorphic, irregularly shaped calicifications heterogeneous in size shaped calicifications heterogeneous in size and morphology raises much greater and morphology raises much greater concern about malignancy. concern about malignancy.

Calcifications are analyzed according to Calcifications are analyzed according to their size, shape, number, and distribution. their size, shape, number, and distribution. The general rule is that larger, round or oval The general rule is that larger, round or oval shaped calcifications uniform in size has a shaped calcifications uniform in size has a higher probability of being associated with a higher probability of being associated with a benign process and smaller, irregular, benign process and smaller, irregular, polymorphic, branching calcifications polymorphic, branching calcifications heterogeneous in size and morphology are heterogeneous in size and morphology are more often associated with a malignant more often associated with a malignant process. Certain calcification patterns are process. Certain calcification patterns are almost always pathognomic of a benign almost always pathognomic of a benign process, and in such cases no further process, and in such cases no further analysis is needed. analysis is needed.

In the majority of cases, however, a pattern In the majority of cases, however, a pattern of calcification deposition is inconclusive of calcification deposition is inconclusive and may be attributable to either a benign or and may be attributable to either a benign or malignant process. Needless to say, these malignant process. Needless to say, these cases require additional evaluation such as cases require additional evaluation such as using magnification mammography to using magnification mammography to further elucidate the calcifications' further elucidate the calcifications' morphology and distribution. morphology and distribution.

SizeSize Generally speaking, microcalcifications are Generally speaking, microcalcifications are

associated with a malignant process and associated with a malignant process and macrocalcifications are associated with a benign macrocalcifications are associated with a benign process. The problem with this general rule is that process. The problem with this general rule is that there is no fine line of measurement that could there is no fine line of measurement that could enable one to distinguish between micro and enable one to distinguish between micro and macro. All calcifications start out imperceptably macro. All calcifications start out imperceptably small and radiographically invisible. Most small and radiographically invisible. Most radiologists place calcifications 0.5 mm or less to radiologists place calcifications 0.5 mm or less to have a high probability of association with cancer; have a high probability of association with cancer; and calcifications of 2.0 mm or larger are typical of and calcifications of 2.0 mm or larger are typical of a benign process. The smallest visible a benign process. The smallest visible calcifications on a mammogram is approximately calcifications on a mammogram is approximately 0.2 - 0.3 mm. 0.2 - 0.3 mm.

NumberNumber

The number of calcifications that make up a The number of calcifications that make up a cluster has been used as an indicator of benign cluster has been used as an indicator of benign and malignancy. While the actual number itself is and malignancy. While the actual number itself is arbitrary, radiologists tend to agree that the arbitrary, radiologists tend to agree that the minimum number of calcifications be either four, minimum number of calcifications be either four, five, or six to be of significance. Any number of five, or six to be of significance. Any number of calcifications less than four will rarely lead to the calcifications less than four will rarely lead to the detection of breast cancer in and of itself. Again, detection of breast cancer in and of itself. Again, as with all criteria in mammographic analysis, no as with all criteria in mammographic analysis, no number is absolute and two or three calcifications number is absolute and two or three calcifications may merit greater suspicion if they exhibit may merit greater suspicion if they exhibit worrisome morphologies. worrisome morphologies.

MorphologyMorphology

The morphology of calcifications is considered to The morphology of calcifications is considered to be the most important indicator in differentiating be the most important indicator in differentiating benign from malignant. As noted earlier, round benign from malignant. As noted earlier, round and oval shaped calcifications that are also and oval shaped calcifications that are also uniform in shape and size are more likely to be on uniform in shape and size are more likely to be on the benign end of the spectrum. Calcifications that the benign end of the spectrum. Calcifications that are irregular in shape and size fall closer to the are irregular in shape and size fall closer to the malignant end of the spectrum. It has been malignant end of the spectrum. It has been described that calcifications associated with a described that calcifications associated with a malignant process resemble small fragments of malignant process resemble small fragments of broken glass and are rarely round or smooth. broken glass and are rarely round or smooth.

DistributionDistribution Distribution modifiers (grouped or clustered, Distribution modifiers (grouped or clustered,

linear, segmental, regional, diffuse) are used to linear, segmental, regional, diffuse) are used to describe the arrangement of the calcifications. describe the arrangement of the calcifications.

GroupedGrouped or or clusteredclustered should be used to describe should be used to describe calcifications that occupy a small volume (<2 µL) calcifications that occupy a small volume (<2 µL) of tissue.of tissue.

Calcifications that are Calcifications that are linearly distributedlinearly distributed are are arranged in a line and may have branch points.arranged in a line and may have branch points.

Segmentally distributedSegmentally distributed calcifications suggest calcifications suggest deposition of calcification in a duct and its deposition of calcification in a duct and its branches. This type of calcification may be branches. This type of calcification may be secondary to benign or malignant processes.secondary to benign or malignant processes.

Regionally distributedRegionally distributed calcifications are most calcifications are most likely due to benign processes. These likely due to benign processes. These calcifications are scattered in a large volume calcifications are scattered in a large volume of the breast and do not necessarily conform of the breast and do not necessarily conform to a ductal distribution.to a ductal distribution.

Diffusely distributedDiffusely distributed calcifications are calcifications are scattered randomly throughout the breast.scattered randomly throughout the breast.

Benign Calcifications Benign Calcifications Skin or dermal calcificationsSkin or dermal calcifications are usually identified as spherical, lucent-centered are usually identified as spherical, lucent-centered

calcifications at the periphery of the breast, calcifications at the periphery of the breast, especially in the inferior, posterior, and medial especially in the inferior, posterior, and medial Usually, skin calcifications are readily Usually, skin calcifications are readily distinguished as benign findings. However, in distinguished as benign findings. However, in some cases, additional imaging is needed to some cases, additional imaging is needed to differentiate skin calcifications from more differentiate skin calcifications from more worrisome calcifications.worrisome calcifications.When mammograms are compared, calcifications When mammograms are compared, calcifications that maintain a fixed relationship to one another that maintain a fixed relationship to one another are suggestive of a dermal location. Magnification are suggestive of a dermal location. Magnification views may be used to demonstrate the lucent views may be used to demonstrate the lucent centers characteristic of skin calcifications. centers characteristic of skin calcifications.

Vascular calcificationsVascular calcifications

are commonly identified on mammography, are commonly identified on mammography, especially in older women. Vascular calcifications, especially in older women. Vascular calcifications, which are usually secondary to medial which are usually secondary to medial atherosclerosis, often demonstrate a characteristic atherosclerosis, often demonstrate a characteristic train tracklike configuration. In some cases, it may train tracklike configuration. In some cases, it may be difficult to distinguish vascular calcifications be difficult to distinguish vascular calcifications from ductal calcifications (including calcifications from ductal calcifications (including calcifications representing ductal carcinoma in situ). Arterial representing ductal carcinoma in situ). Arterial calcification in the breasts may be associated with calcification in the breasts may be associated with diabetes and hyperparathyroidism.diabetes and hyperparathyroidism.

Lucent-centered calcificationsLucent-centered calcifications

which are round or oval, are almost always which are round or oval, are almost always benign and they have thicker walls than benign and they have thicker walls than those of rim or eggshell calcifications. Skin those of rim or eggshell calcifications. Skin calcifications are often lucent-centered, and calcifications are often lucent-centered, and lucent-centered calcifications may form lucent-centered calcifications may form around benign debris in the ducts. Other around benign debris in the ducts. Other entities that may appear as lucent-centered entities that may appear as lucent-centered calcifications on mammography include calcifications on mammography include silicone granulomas and fat necrosissilicone granulomas and fat necrosis

Eggshell or rim calcificationsEggshell or rim calcifications

are thin and appear as calcium deposited on the are thin and appear as calcium deposited on the surface of a sphere. The walls of eggshell or rim surface of a sphere. The walls of eggshell or rim calcifications are thinner than the walls of lucent-calcifications are thinner than the walls of lucent-centered calcifications.centered calcifications.The entire circumference of an eggshell The entire circumference of an eggshell calcification does not need to be completely calcification does not need to be completely calcified to represent a benign finding. Although fat calcified to represent a benign finding. Although fat necrosis can result in eggshell calcifications, necrosis can result in eggshell calcifications, calcification in the walls of cysts is the most calcification in the walls of cysts is the most common cause of eggshell or rim calcifications. common cause of eggshell or rim calcifications.

Coarse or popcorn like calcificationsCoarse or popcorn like calcificationsare associated with the involution and are associated with the involution and hyaline degeneration of fibroadenomas. hyaline degeneration of fibroadenomas. Fibroadenomas are the most common Fibroadenomas are the most common breast masses seen in women younger than breast masses seen in women younger than 35 years of age.35 years of age.Calcifications in fibroadenomas usually Calcifications in fibroadenomas usually begin at the periphery and then involve the begin at the periphery and then involve the central portion of the fibroadenoma. central portion of the fibroadenoma. Fibroadenomas may be completely replaced Fibroadenomas may be completely replaced by calcification without a mass discernible by calcification without a mass discernible by mammography. by mammography.

Large rodlike, or secretory calcificationsLarge rodlike, or secretory calcifications

are oriented along the axes of the ductal system. are oriented along the axes of the ductal system. These calcifications result from calcification of These calcifications result from calcification of ductal secretions. Large rodlike calcifications may ductal secretions. Large rodlike calcifications may have lucent centers if the ductal secretions have lucent centers if the ductal secretions undergo peripheral calcification. In general, these undergo peripheral calcification. In general, these calcifications are coarser and larger (usually > 1 calcifications are coarser and larger (usually > 1 mm in diameter) than malignant calcifications. mm in diameter) than malignant calcifications. Large rod like calcifications are commonly bilateral Large rod like calcifications are commonly bilateral and diffuse. These calcifications are associated and diffuse. These calcifications are associated with secretory disease, plasma cell mastitis, and with secretory disease, plasma cell mastitis, and duct ectasia. duct ectasia.

Round and punctate calcificationsRound and punctate calcifications

Punctate calcifications are spherical Punctate calcifications are spherical calcifications that have well-defined calcifications that have well-defined margins.They usually measure less than 0.5 margins.They usually measure less than 0.5 mm in diameter. mm in diameter.

Round calcifications are benign spherical Round calcifications are benign spherical calcifications that may vary in size. When calcifications that may vary in size. When less than 1 mm, round calcifications are less than 1 mm, round calcifications are frequently formed in the acini of the lobules. frequently formed in the acini of the lobules.

Suture calcificationsSuture calcificationsSuture material may become calcified, Suture material may become calcified, resulting in suture calcifications.20,21 resulting in suture calcifications.20,21 Suture calcifications are usually seen at a Suture calcifications are usually seen at a known surgical site, and the calcifications known surgical site, and the calcifications may be linear or tubular. Knots may be may be linear or tubular. Knots may be demonstrated. Suture calcifications are demonstrated. Suture calcifications are likely due to delayed resorption of catgut likely due to delayed resorption of catgut sutures, which can provide a matrix on sutures, which can provide a matrix on which calcium can precipitate.which calcium can precipitate.

Calcifications that are of Calcifications that are of intermediate concernintermediate concern

Amorphous calcifications: Amorphous calcifications: These are very These are very tiny, hazy calcifications and are often difficult tiny, hazy calcifications and are often difficult to pick up on CR machinesto pick up on CR machines

Calcifications that are highly Calcifications that are highly suspicious for malignancysuspicious for malignancy

Fine, linear, branching or casting Fine, linear, branching or casting calcifications:calcifications:

These are linear, rod-like calcifications and These are linear, rod-like calcifications and are typically seen in malignancy are typically seen in malignancy

Pleomorphic calcifications:Pleomorphic calcifications:

These are microcalcifications of varying These are microcalcifications of varying shapes and sizes shapes and sizes

ASYMMETRIC DENSITYASYMMETRIC DENSITY The breasts are seen as symmetric The breasts are seen as symmetric

structures and should be compared as such. structures and should be compared as such. An asymmetric area may be indicative of a An asymmetric area may be indicative of a developing mass, a variation of normal developing mass, a variation of normal breast tissue, postoperative change from a breast tissue, postoperative change from a previous biopsy, or merely poor positioning previous biopsy, or merely poor positioning and compression during imaging. The and compression during imaging. The appearance of asymmetries due to appearance of asymmetries due to positioning and compression during imaging positioning and compression during imaging is often the result of superimposition of is often the result of superimposition of normal breast structures. normal breast structures.

True breast asymmetry, on the other hand, is True breast asymmetry, on the other hand, is three-dimensional and should be present on both three-dimensional and should be present on both MLO and CC views. Once an asymmetry is MLO and CC views. Once an asymmetry is determined to be real, the interpreter must determined to be real, the interpreter must determine whether the asymmetry is a benign determine whether the asymmetry is a benign variation of asymmetric breast tissue or a focal variation of asymmetric breast tissue or a focal asymmetric density that may represent a asymmetric density that may represent a significant mass. If the former determination could significant mass. If the former determination could not be made, further evalution is necessary to not be made, further evalution is necessary to clarify if the focal asymmetric density may possibly clarify if the focal asymmetric density may possibly be a malignant process. be a malignant process.

ASSESSMENT CATEGORIESASSESSMENT CATEGORIES

Category 0 / Need Additional Imaging Evaluation Category 0 / Need Additional Imaging Evaluation Finding for which additional imaging evaluation is needed. Finding for which additional imaging evaluation is needed. This is almost always used in a screening situation and This is almost always used in a screening situation and should rarely be used after a full imaging work up. A should rarely be used after a full imaging work up. A recommendation for additional imaging evaluation includes recommendation for additional imaging evaluation includes the use of spot compression, magnification, special the use of spot compression, magnification, special mammographic views, ultrasound, etc. Whenever possible, mammographic views, ultrasound, etc. Whenever possible, the present mammogram should be compared to previous the present mammogram should be compared to previous studies. The radiologist should use judgment in how studies. The radiologist should use judgment in how vigorously to pursue previous studies.vigorously to pursue previous studies.

Category 1 / NegativeCategory 1 / Negative There is nothing to comment on. The breasts are There is nothing to comment on. The breasts are symmetrical and no masses, architectural disturbances or symmetrical and no masses, architectural disturbances or suspicious calcifications are presentsuspicious calcifications are present

Category 2 / Benign Finding Category 2 / Benign Finding

This is also a negative mammogram, but the This is also a negative mammogram, but the interpreter may wish to describe a finding. interpreter may wish to describe a finding. Involuting, calcified fibroadenomas, multiple Involuting, calcified fibroadenomas, multiple secretory calcifications, fat containing lesions such secretory calcifications, fat containing lesions such as oil cysts, lipomas, galactoceles, and mixed as oil cysts, lipomas, galactoceles, and mixed density hamartomas all have characteristic density hamartomas all have characteristic appearances, and may be labeled with appearances, and may be labeled with confidence. The interpreter might wish to describe confidence. The interpreter might wish to describe intramammary lymph nodes, implants, etc. while intramammary lymph nodes, implants, etc. while still concluding that there is no mammographic still concluding that there is no mammographic evidence of malignancy.evidence of malignancy.

Category 3 / Probably Benign Finding - Short Category 3 / Probably Benign Finding - Short Interval Follow-Up SuggestedInterval Follow-Up Suggested A finding placed in this category should have a A finding placed in this category should have a very high probability of being benign. It is not very high probability of being benign. It is not expected to change over the follow-up interval, but expected to change over the follow-up interval, but the radiologist would prefer to establish its the radiologist would prefer to establish its stability. Data are becoming available that shed stability. Data are becoming available that shed light on the efficacy of short interval follow-up. At light on the efficacy of short interval follow-up. At the present time, most approaches are intuitive. the present time, most approaches are intuitive. These will likely undergo future modification as These will likely undergo future modification as more data accrue as to the validity of an approach, more data accrue as to the validity of an approach, the interval required, and the type of findings that the interval required, and the type of findings that should be followed.should be followed.

Category 4 / Suspicious Abnormality - Biopsy Category 4 / Suspicious Abnormality - Biopsy Should Be ConsideredShould Be Considered These are lesions that do not have the These are lesions that do not have the characteristic morphologies of breast cancer but characteristic morphologies of breast cancer but have a definite probability of being malignant. The have a definite probability of being malignant. The radiologist has sufficient concern to urge a biopsy. radiologist has sufficient concern to urge a biopsy. If possible, the relevant probabilities should be If possible, the relevant probabilities should be cited so that the patient and her physician can cited so that the patient and her physician can make the decision on the ultimate course of make the decision on the ultimate course of action.action.

Category 5 / Highly Suggestive of Malignancy - Category 5 / Highly Suggestive of Malignancy - Appropriate Action Should Be TakenAppropriate Action Should Be Taken These lesions have a high probability of being These lesions have a high probability of being cancercancer

Category 6: Biopsy proven malignancyCategory 6: Biopsy proven malignancy

Digital Mammography Digital Mammography One of the most recent advances in x-ray One of the most recent advances in x-ray

mammography is digital mammography. Digital mammography is digital mammography. Digital (computerized) mammography is similar to (computerized) mammography is similar to standard mammography in that x-rays are used to standard mammography in that x-rays are used to produce detailed images of the breast. Digital produce detailed images of the breast. Digital mammography uses essentially the same mammography uses essentially the same mammography system as conventional mammography system as conventional mammography, but the system is equipped with a mammography, but the system is equipped with a digital receptor and a computer instead of a film digital receptor and a computer instead of a film cassette. Several studies have demonstrated that cassette. Several studies have demonstrated that digital mammography is at least as accurate as digital mammography is at least as accurate as standard mammography. standard mammography.

How Does Digital Mammography How Does Digital Mammography Differ From Standard Mammography?Differ From Standard Mammography? In standard mammography, images are recorded In standard mammography, images are recorded

on film using an x-ray cassette. The film is viewed on film using an x-ray cassette. The film is viewed by the radiologist using a "light box" and then by the radiologist using a "light box" and then stored in a jacket. With digital mammography, the stored in a jacket. With digital mammography, the breast image is captured using a special electronic breast image is captured using a special electronic x-ray detector, which converts the image into a x-ray detector, which converts the image into a digital picture for review on a computer monitor. digital picture for review on a computer monitor. The digital mammogram is then stored on a The digital mammogram is then stored on a computer. With digital mammography, the computer. With digital mammography, the magnification, orientation, brightness, and contrast magnification, orientation, brightness, and contrast of the image may be altered after the exam is of the image may be altered after the exam is completed to help the radiologist more clearly see completed to help the radiologist more clearly see certain areas. certain areas.

Digital mammography may provide additional Digital mammography may provide additional benefits, such as lower radiation doses and higher benefits, such as lower radiation doses and higher sensitivity to abnormalities. sensitivity to abnormalities.

The use of digital mammography can lead to fewer The use of digital mammography can lead to fewer "recalls" (repeat mammograms) than film "recalls" (repeat mammograms) than film mammography.mammography.

Other data from German researchers suggest that Other data from German researchers suggest that the radiation dose can be reduced by up to 50% the radiation dose can be reduced by up to 50% with digital mammography and still detect breast with digital mammography and still detect breast cancer as well as the standard radiation dose of cancer as well as the standard radiation dose of film mammography. film mammography.

Digital mammography systems cost approximately Digital mammography systems cost approximately 1.5 to 4 times as much as standard film 1.5 to 4 times as much as standard film mammography systems.mammography systems.

While procedural time saved by using digital While procedural time saved by using digital mammography over standard film mammography mammography over standard film mammography justifies part of the cost for facilities that perform justifies part of the cost for facilities that perform several thousand mammograms each year, the several thousand mammograms each year, the study will determine whether the high cost of study will determine whether the high cost of digital mammography is justifiable in terms of its digital mammography is justifiable in terms of its benefits in detecting breast cancer. benefits in detecting breast cancer.

From the patient's perspective, a digital From the patient's perspective, a digital mammogram is the same as a standard film-based mammogram is the same as a standard film-based mammogram in that breast compression and mammogram in that breast compression and radiation are necessary to create clear images of radiation are necessary to create clear images of the breast.the breast.

The time needed to position the patient is the The time needed to position the patient is the same for each method. However, conventional film same for each method. However, conventional film mammography requires several minutes to mammography requires several minutes to develop the film while digital mammography develop the film while digital mammography provides the image on the computer monitor in provides the image on the computer monitor in less than a minute after the exposure/data less than a minute after the exposure/data acquisition. Thus, digital mammography provides acquisition. Thus, digital mammography provides a shorter exam for the woman and may possibly a shorter exam for the woman and may possibly allow mammography facilities to conduct more allow mammography facilities to conduct more mammograms in a day.mammograms in a day.

Digital mammography can also be manipulated to Digital mammography can also be manipulated to correct for under or over exposure after the exam correct for under or over exposure after the exam is completed, eliminating the need for some is completed, eliminating the need for some women to undergo repeat mammograms before women to undergo repeat mammograms before leaving the facility. leaving the facility.

With digital mammography, the With digital mammography, the magnification, orientation, brightness, and magnification, orientation, brightness, and contrast of the mammogram image may contrast of the mammogram image may also be altered after the exam is completed also be altered after the exam is completed to help the radiologist more clearly see to help the radiologist more clearly see certain areas of the breast. certain areas of the breast.

In the near future, digital mammography may In the near future, digital mammography may provide many benefits over standard film provide many benefits over standard film mammography. mammography. These benefits include:These benefits include:

Improved contrastImproved contrast between dense and non-dense between dense and non-dense breast tissue breast tissue

Faster image acquisitionFaster image acquisition (less than a minute) (less than a minute) Shorter exam time (approximately half that of film-Shorter exam time (approximately half that of film-

based mammography) based mammography) Easier image Easier image storage storage Ability to Ability to correct under or over-exposurecorrect under or over-exposure of films of films

without having to repeat mammograms without having to repeat mammograms Transmittal of imagesTransmittal of images over phone lines or a over phone lines or a

network for remote consultation with other network for remote consultation with other physiciansphysicians

According to one study results, digital and standard According to one study results, digital and standard film mammography had similar accuracy rates for film mammography had similar accuracy rates for many women. However, digital mammography was many women. However, digital mammography was significantly better at screening women in any of the significantly better at screening women in any of the following categories: following categories:

under age 50, regardless of what level of breast tissue under age 50, regardless of what level of breast tissue density they had density they had

of any age with very dense or extremely dense of any age with very dense or extremely dense breasts breasts

pre- or perimenopausal women of any age (defined as pre- or perimenopausal women of any age (defined as women who had a last menstrual period within 12 women who had a last menstrual period within 12 months of their mammograms)months of their mammograms)

The study showed no benefit for post-menopausal The study showed no benefit for post-menopausal women over age 50 who did not have dense breast women over age 50 who did not have dense breast tissue. tissue.

Disadvantages to Digital MammographyDisadvantages to Digital Mammography While digital mammography is quite promising, it still has While digital mammography is quite promising, it still has additional hurdles to undergo before it replaces additional hurdles to undergo before it replaces conventional mammography. Digital mammography must: conventional mammography. Digital mammography must:

provide higher detail resolution (as standard provide higher detail resolution (as standard mammography does) mammography does)

become less expensive (digital mammography is currently become less expensive (digital mammography is currently several times more costly than conventional several times more costly than conventional mammography) mammography)

provide a method to efficiently compare digital provide a method to efficiently compare digital mammogram images with existing mammography films on mammogram images with existing mammography films on computer monitorscomputer monitors

Standard mammography using film cassettes has the Standard mammography using film cassettes has the benefit of providing very high detail resolution (image benefit of providing very high detail resolution (image sharpness), which is especially useful for imaging sharpness), which is especially useful for imaging microcalcifications (tiny calcium deposits) and very small microcalcifications (tiny calcium deposits) and very small abnormalities that may indicate early breast cancer. abnormalities that may indicate early breast cancer.

The high cost of digital mammography is a major obstacle. The high cost of digital mammography is a major obstacle.

SonomammographySonomammography1. Equipment requirements1. Equipment requirements

Linear array or annular array transducer Linear array or annular array transducer configurations are suitable for high quality images. configurations are suitable for high quality images. The dominant transducer frequency should be 7.5 The dominant transducer frequency should be 7.5 MHz or higher, preferably of a broad bandwidth MHz or higher, preferably of a broad bandwidth construction . construction . However, high frequency on its own is not a However, high frequency on its own is not a sufficient parameter to ensure quality. sufficient parameter to ensure quality. A penetration depth of at least 4 cm with A penetration depth of at least 4 cm with selectable focal regions is required.selectable focal regions is required.

A field of view greater than 4 cm is A field of view greater than 4 cm is preferable for large area examinations, and preferable for large area examinations, and smaller fields are suitable for detailed smaller fields are suitable for detailed examination of specific findings. examination of specific findings. 2. Examination technique2. Examination techniqueIn order to evaluate breast anatomy and In order to evaluate breast anatomy and not to miss subtle pathology, the not to miss subtle pathology, the examination should be:-examination should be:-

SystematicSystematic Comprehensive Comprehensive Reproducible Reproducible

SystematicSystematic1.1. A planned approach for performance and A planned approach for performance and

documentation of the examination is documentation of the examination is required. required.

2.2. When a specific lesion is examined, its When a specific lesion is examined, its precise position should be noted on the precise position should be noted on the image and its correlation with the clinical image and its correlation with the clinical and mammographic findings recorded. and mammographic findings recorded.

3.3. When the total breast volume needs to be When the total breast volume needs to be assessed, overlapping scans will ensure assessed, overlapping scans will ensure complete examination. complete examination. 

comprehensivecomprehensiveAll breast structures must All breast structures must be completely displayed, and particular care be completely displayed, and particular care taken in the area of interest to ensure that taken in the area of interest to ensure that normal anatomical and/or pathological normal anatomical and/or pathological findings are recognized and recorded. findings are recognized and recorded. 

reproduciblereproducibleThe imaging results must be The imaging results must be readily reproducible, and ultrasonic findings readily reproducible, and ultrasonic findings should be clearly identified on the stored should be clearly identified on the stored images. It should be possible to confirm the images. It should be possible to confirm the same appearances on different types of high same appearances on different types of high resolution ultrasonic scanning systems. resolution ultrasonic scanning systems. 

As the acquisition of ultrasonic images is very As the acquisition of ultrasonic images is very operator dependent, a thorough understanding of operator dependent, a thorough understanding of the physical principles of ultrasound and of the the physical principles of ultrasound and of the normal anatomy are essential to achieve high normal anatomy are essential to achieve high quality images. quality images.

Supine oblique or supine position is recommended Supine oblique or supine position is recommended to reduce breast thickness and to improve to reduce breast thickness and to improve visualization of deeper tissues. The reduced visualization of deeper tissues. The reduced thickness allows optimization of focusing. thickness allows optimization of focusing.

One or both arms should be elevated behind the One or both arms should be elevated behind the head or neck to stretch the pectoralis muscle for head or neck to stretch the pectoralis muscle for better fixation and immobilization of the breast. better fixation and immobilization of the breast.

When scanning, the transducer should always be When scanning, the transducer should always be perpendicular to the skin surface. perpendicular to the skin surface.

Transducer coupling to the skin surface should be Transducer coupling to the skin surface should be gentle and should give complete contact. gentle and should give complete contact.

Strong compression pushes lesions out of the Strong compression pushes lesions out of the scanning plane below the transducer and should scanning plane below the transducer and should be avoided as it deforms tissue structures making be avoided as it deforms tissue structures making interpretation more difficult. interpretation more difficult.

Compression is useful to avoid refraction and Compression is useful to avoid refraction and scattering from normal anatomical structures when scattering from normal anatomical structures when sound penetration is insufficient, and to examine sound penetration is insufficient, and to examine tissue elasticity of benign and malignant findings. tissue elasticity of benign and malignant findings.

The scanning procedure should involve The scanning procedure should involve overlapping scanning planes. These may be overlapping scanning planes. These may be parasagittal, transverse, radial, or antiradial. parasagittal, transverse, radial, or antiradial. Radial and antiradial scans follow normal Radial and antiradial scans follow normal anatomical patterns, assisting the anatomical patterns, assisting the recognition of abnormalities and better recognition of abnormalities and better demonstrating ductal structure and changes. demonstrating ductal structure and changes.

3. Interpretation3. Interpretation

Ultrasonic examination of the breast is Ultrasonic examination of the breast is difficult and requires:-difficult and requires:-

a) Detailed knowledge of anatomy, a) Detailed knowledge of anatomy, physiological changes and benign and physiological changes and benign and malignant pathology.malignant pathology.

b) Correlation of findings with other imaging b) Correlation of findings with other imaging results, clinical information and examination.results, clinical information and examination.

Imaging features to be assessed:Imaging features to be assessed:

Lesion featuresLesion features Adjacent featuresAdjacent features

Shape (including Shape (including depth/width ratio)  depth/width ratio) 

Architectural Architectural pattern  pattern 

Boundaries/margins Boundaries/margins (including edge (including edge refraction)  refraction) 

Fibroglandular Fibroglandular echogenicity  echogenicity 

Internal echo Internal echo texture  texture 

Fat echogenicity  Fat echogenicity 

Through Through transmission transmission (enhancement, (enhancement, shadowing)  shadowing) 

Cooper's ligament Cooper's ligament thickness  thickness 

Lesion featuresLesion features Adjacent featuresAdjacent features

Calcifications  Calcifications  Skin thickness  Skin thickness 

Ductal alterations Ductal alterations

The minimum report should include:The minimum report should include: The indications for the examination The indications for the examination A description of any lesion(s) and adjacent A description of any lesion(s) and adjacent

features including the size of maximum features including the size of maximum diameter(s) or extent diameter(s) or extent

The position of the lesion(s) as represented on a The position of the lesion(s) as represented on a clock face with its distance from the nipple clock face with its distance from the nipple

Correlation with clinical and/or mammographic or Correlation with clinical and/or mammographic or other imaging findings other imaging findings

Opinion regarding provisional diagnosis(es) and Opinion regarding provisional diagnosis(es) and significance of finding(s)significance of finding(s)

4. Interventional procedures4. Interventional procedures Guided interventional procedures include:-Guided interventional procedures include:-

1)1) Cytology and core biopsy Cytology and core biopsy

2)2) Abscess drainage Abscess drainage

3)3) Preoperative localization: hookwire placement, Preoperative localization: hookwire placement, carbon tracking, and radionuclide marking carbon tracking, and radionuclide marking

4)4) Intraoperative localization or localization Intraoperative localization or localization

5)5) Radionuclide injection for sentinel node Radionuclide injection for sentinel node identification identification

6)6) Specimen imaging for verification of lesion Specimen imaging for verification of lesion removalremoval

5. Accuracy and confidence.5. Accuracy and confidence. Accuracy and confidence in interpretation Accuracy and confidence in interpretation

requires experience.requires experience. Continuous education and follow up are Continuous education and follow up are

essential to improve and maintain skills in essential to improve and maintain skills in technique and interpretation. technique and interpretation.

Normal breast parenchymal patternsNormal breast parenchymal patterns

Breast ultrasound: criteria for benign Breast ultrasound: criteria for benign lesions lesions

Smooth and well circumscribedSmooth and well circumscribed Hyperechoic, isoechoic or mildly Hyperechoic, isoechoic or mildly

hypoechoichypoechoic Thin echogenic capsuleThin echogenic capsule Ellipsoid shape, with the maximum Ellipsoid shape, with the maximum

diameter being in the transverse planediameter being in the transverse plane Three or fewer gentle lobulationsThree or fewer gentle lobulations Absence of any malignant findingsAbsence of any malignant findings

Breast cysts Breast cysts Breast cysts are the commonest cause of breast Breast cysts are the commonest cause of breast

lumps in women between 35 and 50 years of lumps in women between 35 and 50 years of age.A cyst occurs when fluid accumulates due to age.A cyst occurs when fluid accumulates due to obstruction of the extralobular terminal ducts, obstruction of the extralobular terminal ducts, either due to fibrosis or because of intraductal either due to fibrosis or because of intraductal epithelial proliferation. A cyst is seen on USG as a epithelial proliferation. A cyst is seen on USG as a well-defined, round or oval, anechoic structure well-defined, round or oval, anechoic structure with a thin wall .They may be solitary or multiple. with a thin wall .They may be solitary or multiple. Complex cystComplex cyst: When internal echoes or debris are : When internal echoes or debris are seen, the cyst is called a complex cyst. These seen, the cyst is called a complex cyst. These internal echoes may be caused by floating internal echoes may be caused by floating cholesterol crystals, pus, blood or milk of calcium cholesterol crystals, pus, blood or milk of calcium crystals crystals

Cysts usually reveal thin walls and through transmission (A). An inflamed cyst (B) reveals A thick edematous wall (arrow) with internal layering of thick/thin fluid (arrowhead). A galactocele (C) reveals diffuse low-level echoes in the cyst. chronic abscess (D) seen in this extended views shows an an irregular pseudo-wall (arrow) with dirty internal echoes due

to pus or debris (X).

Duct ectasia Duct ectasia

This lesion has a variable appearance. This lesion has a variable appearance. Typically, duct ectasia may appear as a Typically, duct ectasia may appear as a single tubular structure filled with fluid or single tubular structure filled with fluid or sometimes may show multiple such sometimes may show multiple such structures as well. Old cellular debris may structures as well. Old cellular debris may appear as echogenic content. If the debris appear as echogenic content. If the debris fills the lumen, it can be sometimes fills the lumen, it can be sometimes mistaken for a solid mass, unless the tubular mistaken for a solid mass, unless the tubular shape is picked up. shape is picked up.

Longitudinal image (A) shows a dilated duct containing inspissated debris Longitudinal image (A) shows a dilated duct containing inspissated debris (arrow) is seen. In crosssection (B), the intraductal debris may appear as (arrow) is seen. In crosssection (B), the intraductal debris may appear as

a focal lesion (arrowheads)a focal lesion (arrowheads)

Fibroadenoma Fibroadenoma

Fibroadenoma is an estrogen-induced tumor that forms in Fibroadenoma is an estrogen-induced tumor that forms in adolescence. It is the third most common breast lesion adolescence. It is the third most common breast lesion after fibrocystic disease and carcinoma. It usually presents after fibrocystic disease and carcinoma. It usually presents as a firm, smooth, oval-shaped, freely movable mass. It is as a firm, smooth, oval-shaped, freely movable mass. It is rarely tender or painful. The size is usually under 5 cm, rarely tender or painful. The size is usually under 5 cm, though larger fibroadenomas are known. Calcifications may though larger fibroadenomas are known. Calcifications may occur. On USG, it appears as a well-defined lesion]. A occur. On USG, it appears as a well-defined lesion]. A capsule can usually be identified. The echotexture is capsule can usually be identified. The echotexture is usually homogenous and hypoechoic as compared to the usually homogenous and hypoechoic as compared to the breast parenchyma, and there may be low-level internal breast parenchyma, and there may be low-level internal echoes. Typically, the transverse diameter is greater than echoes. Typically, the transverse diameter is greater than the anteroposterior diameter. In a small number of patients, the anteroposterior diameter. In a small number of patients, the mass may appear complex, hyperechoic or isoechoic the mass may appear complex, hyperechoic or isoechoic

Transvere image reveals a typical larger transverse than anteroposterior Transvere image reveals a typical larger transverse than anteroposterior

diameter, homogenous echotexture, and a thin capsule (arrowheads)diameter, homogenous echotexture, and a thin capsule (arrowheads)

Lipoma Lipoma

Lipoma is a slow-growing, well-defined Lipoma is a slow-growing, well-defined tumor. The tumor is soft and can be tumor. The tumor is soft and can be deformed by compression with the deformed by compression with the transducer. A thin capsule can usually be transducer. A thin capsule can usually be identified and the tumor often reveals an identified and the tumor often reveals an echogenic structure, with a stippled or echogenic structure, with a stippled or lamellar appearance lamellar appearance

Sagittal extended view reveals a subtle echogenic mass with Sagittal extended view reveals a subtle echogenic mass with

a reticular pattern and a well-defined, thin capsule (arrows)a reticular pattern and a well-defined, thin capsule (arrows)

Characteristics of malignant lesionsCharacteristics of malignant lesions

Malignant lesions are commonly hypoechoic Malignant lesions are commonly hypoechoic lesions with ill-defined borders. Typically, a lesions with ill-defined borders. Typically, a malignant lesion presents as a hypoechoic nodular malignant lesion presents as a hypoechoic nodular lesion, which is ‘taller than broader’ and has lesion, which is ‘taller than broader’ and has spiculated margins, posterior acoustic shadowing spiculated margins, posterior acoustic shadowing and microcalcifications. The spiky extensions and microcalcifications. The spiky extensions along the tissue planes can be well seen in along the tissue planes can be well seen in coronal images .It was initially believed that color coronal images .It was initially believed that color Doppler scanning would add to the specificity of Doppler scanning would add to the specificity of USG examination, but this has not proven to be USG examination, but this has not proven to be very efficacious; however, in certain situations it very efficacious; however, in certain situations it does help resolve the issue, particularly when does help resolve the issue, particularly when there is significant vascularity present within highly there is significant vascularity present within highly cellular types of malignancies cellular types of malignancies

Breast MRIBreast MRI (MR mammography) (MR mammography) Magnetic resonance

imaging of the breast is particularly useful in imaging of the breast is particularly useful in evaluation of newly diagnosed breast evaluation of newly diagnosed breast cancer,cancer,

in women whose breast tissue is in women whose breast tissue is mammographically very dense and for,mammographically very dense and for,

screening in women with a high lifetime risk screening in women with a high lifetime risk of breast cancer because of their family of breast cancer because of their family history or genetic disposition.history or genetic disposition.

Breast MRI can be performed on all Breast MRI can be performed on all standard whole body magnets at a field standard whole body magnets at a field strength of 0.5 T - 1.5 Tesla. strength of 0.5 T - 1.5 Tesla.

The use of a dedicated bilateral breast coil The use of a dedicated bilateral breast coil is obligatory. is obligatory.

Breast cancer is detectable due to the Breast cancer is detectable due to the strong enhancement in dynamic breast strong enhancement in dynamic breast imaging that peaks early (about 1-2 min) imaging that peaks early (about 1-2 min) after contrast medium injection. If breast after contrast medium injection. If breast cancer is suspected, a breast biopsy may cancer is suspected, a breast biopsy may be necessary to secure the diagnosis.be necessary to secure the diagnosis.

Requirements in breast MRI Requirements in breast MRI procedures: procedures:

Both breasts must be measured without gaps. Both breasts must be measured without gaps. Temporal resolution should be sufficient to allow Temporal resolution should be sufficient to allow

early imaging after contrast agent with dynamic early imaging after contrast agent with dynamic imaging every 60-120 sec. imaging every 60-120 sec.

For the best possible detection of enhancement fat For the best possible detection of enhancement fat signal should be eliminated either by image signal should be eliminated either by image subtraction or by spectrally selective fat saturation.subtraction or by spectrally selective fat saturation.

Thin slices are necessary to assure absence of Thin slices are necessary to assure absence of partial volume effects. partial volume effects.

Imaging should be performed with a spatial Imaging should be performed with a spatial resolution in plane less than 1 mm.resolution in plane less than 1 mm.

T2 weigthed MR image of both T2 weigthed MR image of both breasts. breasts. 

T1 weighted MR image of both T1 weighted MR image of both breasts. breasts.

T1 weighted MR image of the T1 weighted MR image of the breasts. breasts. 

T1 weighted MR image of both T1 weighted MR image of both breasts with contrast. breasts with contrast.