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Radiological features of breast diseases

Imaging of the breast includes:

Mammography.
Ultrasonography.
Magnetic resonance imaging(MRI)
Galactography (ductography)
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Mammogram
Indications
1. Screening asymptomatic women for breast cancer
2. Evaluation of new breast sign or symptom
3. To assess for bilateral or multifocal disease in a patient with biopsy proven cancer in one breast
4. Placement of localization wire prior to excisional biopsy or for stereotactic core needle biopsy
5. Changes detected during breast palpation.
6. Enlarged axillary lymph nodes.
7. Breast pain regardless of the cycle (mastodynia).
8. Following a surgical treatment of breast cancer - evaluation of the contralateral breast once a year.
9. Family history of breast cancer.
10. Patients during hormonal replacement therapy (MMG once a year, ultrasound every 6 months)
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Normal Mediolateral Oblique View of Left Breast. The pectoralis muscle (arrows) is seen from the axilla to
below the level of the posterior nipple line.
The inframammary fold (curved arrow) is well seen and the nipple is in profile.
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Location in Mammography and US

A complete set of location descriptors consists of:
1.Designation of right or left breast
2.Quadrant and clockface notation (preferably both)
3.On US quarter and clockface notation should be supplemented on the image by means of
bodymark and transducer position.
4.Depth: anterior, middle or posterior third (Mammography only)
5.Distance from nipple
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•A: fatty; breast is almost entirely fat

•B: scattered fibroglandular; breast has scattered areas of fibroglandular density
•C: heterogeneously dense; breast tissue is heterogeneously dense
•D: dense; breast tissue is extremely dense
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Abnormalities seen on mammogram

1-Mass
A 'Mass' is a space occupying 3D lesion seen in two different projections.
If a potential mass is seen in only a single projection it should be called a 'asymmetry' until
its three-dimensionality is confirmed.
1.Shape: oval (may include 2 or 3 lobulations), round or irregular
2.Margins: circumscribed, obscured, microlobulated, indistinct, spiculated
3.Density: high, equal, low or fat-containing.
The images show a fat-containing lesion with a popcorn-like calcification.
All fat-containing lesions are typically benign.
These image-findings are diagnostic for a hamartoma - also known as fibroadenolipoma.
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Pop corn calcification typically benign in hamartoma or also known

as fibro adenolipoma
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Amorphous calcifications
Amorphous or indistinct calcifications are defined as 'without a clearly defined shape
or form'.
These calcifications are usually so small or hazy in appearance, that a more specific
morphologic classification cannot be determined.
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•Diffuse or Scattered: diffuse calcifications

may be scattered calcifications or multiple
similar appearing clusters of calcifications
throughout the whole breast.
•Regional: scattered in a larger volume (> 2
cc) of breast tissue and not in the expected
ductal distribution.
•Clustered : at least 5 calcifications occupy a
small volume of tissue (Linear: calcifications
arrayed in a line, which suggests deposits in a
duct.
•Segmental: calcium deposits in ducts and
branches of a segment or lobe.
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3-Architectural distortion
The term architectural distortion is used,
when the normal architecture is distorted
with no definite mass visible.
This includes thin straight lines or
spiculations radiating from a point, and
focal retraction, distortion or
straightening at the edges of the
parenchyma.
The differential diagnosis is scar tissue or
carcinoma.
Architectural distortion can also be seen
as an associated feature.
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4-Asymmetries

Findings that represent unilateral deposits of fibroglandulair tissue not conforming to the definition
of a mass.
•Asymmetry as an area of fibroglandulair tissue visible on only one mammographic projection,
mostly caused by superimposition of normal breast tissue.
•Focal asymmetry visible on two projections, hence a real finding rather than superposition.
This has to be differentiated from a mass.
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an example of a focal
asymmetry seen on MLO
and CC-view.
Local compression views
and ultrasound did not
show any mass.
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Associated features
Associated features are things that
are seen in association with
suspicious findings like masses,
asymmetries and calcifications.
Associated features play a role in the
final assessment.
For instance a BI-RADS 4-mass
could get a BI-RADS 5 assessment if
seen in association with skin
retraction.
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mediolateral oblique (mammographic images show

circumscribed oval mass in upper outer quadrant
Simple cyst. Craniocaudal
of left breast.
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two examples of a normal male mammogram. Mammography of right male

Focal gynaecomastia can
The left image shows normal skin, a nipple and a small breast gynaecomastia ,there is
variably appear as a
amount of connective tissue behind the nipple. enlargement of breast and
retroareolar, triangular,
The image on the right shows a bit more connective diffuse density
hypoechoic mass.
tissue, but this is still normal.
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hyperdense mass with an

irregular shape and a spiculated
margin.
Notice the focal skin retraction.
This was reported as BI-RADS 5
and proved to be an invasive
ductal carcinoma.
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Breast ultrasound :Indications

1. To better characterize a finding on mammography (eg characterization of a mass not fully assessed by
mammography)
2. evaluation of a palpable mass (differentiate solid from cystic lesions )
3. Evaluation and follow up of breast abscess and inflammation .
4. Guidance for cyst aspiration and core needle biopsy or fine needle aspiration
5. Occasionally to assess implant integrity.
6. Evaluation of Mammographically dense breast.
7. Follow Up of benign lesions in breasts .
8. Evaluation of breasts abnormality during Pregnancy and lactation
9. Breast trauma
10. Breast Pain
11. Nipple discharge

❑Remember : Ultrasound is the First imaging modality for young women ≤ 30 yrs.
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Normal breast tissue showing:

The pre-mammary zone (skin and
overlying breast fat)

The mammary zone (fibroglandular

tissue)

The retro-mammary
zone (predominantly fat and the
muscles of the chest wall)
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Ultrasound finding
1-Dilated ducts either physiological or pathological
2-Mass could be cystic,solid or complex
A- Cyst either simple cyst ( an echoic)
or contains internal debris which could be due to pus( inflammation) ,milk or
blood
B- Complex mass ( Cystic and solid component)
C- Solid masses( iso echoic, hypo echoic or hyper echoic)
3- Calcification ,shadawiong
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Normal lactating breast tissue

The prominent fluid filled ducts and

their echogenic epithelial lining is
readily visible.
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Sonographic features of a simple

cyst include:
•anechoic signal (no internal
echoes)

•smooth walls
•well-circumscribed shape
•enhanced through transmission:
posterior acoustic enhancement
•sharp anterior and posterior
borders
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This patient presented with breast mass and fever. Sonogram shows a round cystic lesion with low-
level internal echoes and increased through transmission. There is increased vascularity peripherally,
but no internal flow
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Lactating breast mass

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Simple V's Complex or complicated cysts

To be simple it must be:

Anechoic
Well cicumbscribed
Have posterior enhancement
It's height should NOT exceed it's width.

A simple cyst adjacent to a complex cyst,

(confirmed by FNA to be a haemorrhagic cyst)
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Same patient
well defined anechoic ovoid lesion with
posterior acoustic enhancement.
25 years women presented with breast pain Final diagnosis: Simple breast cyst.
MLO MAMMOGRAPHY
A well defined intermediate density lesion seen BIRADS 2 Category lesion.
in the inner upper quadrant of left breast.
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A residual complex cyst of 2

cm is detected by
ultrasounds in a
postmenopausal patient.
The patient had many
aspirations of apocrine
breast macro cysts between
the ages of 35 and 45.
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A complex breast cyst:

Sedimentary movement may be visible by scanning the patient erect.

Fine needle aspiration and cytological assessment can confirm the diagnosis.
At the least, a follow-up ultrasound should be performed.
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Papilloma
Whist often benign, their malignant tendency generally leads to removal.

Multiple papillomas have been shown to carry a far greater risk than solitary.
They are fibrovascular growths within milk ducts behind the nipple.

Radiographic ductography has often been employed to confirm the diagnosis, however advancements
in Ductoscopy are proving to be of great benefit.
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A papilloma in a markedly dilated duct.

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The same papilloma imaged in two planes

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Sonographic characteristic in
benign solid lesions of the breast:

1.Smooth and well circumscribed

2.Hyperechoic, isoechoic or mildly
hypoechoic
3.Thin echogenic capsule
4.Ellipsoid shape, with the
maximum diameter being in the
transverse plane
5.Three or fewer gentle lobulations
6.Absence of any malignant findings
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Mammography fibro adenoma

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A Phylloides tumour - confirmed by core biopsy. A large lobulated Phylloides

Note the similarities to a fibroadenoma tumor
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BREAST CARCINOMA
Common ultrasound appearance:
Poorly circumbscribed, hypo echoic mass.
Height greater than width.
Posterior shadowing
You may also see:
•punctate, micro-calcifications
•tethering of adjacent tissues or the mass
crossing tissue boundaries.

Elastography is also an emerging technique in

assisting suspicion levels.
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Lobular breast carcinoma.

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Ductal Carcinoma
The extent of this carcinoma is far more evident on the mammogram.
The peripheral mass and extensive micro-calcification extending towards the nipple is readily
apparent.
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Malignant lesion. A smooth margin and homogenous echotexture suggest a

category 3 lesion. Color Doppler reveals irregularly branching neovascularity
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Sonographic images demonstrating some lymph nodes classified as morphologically normal (A-C)
and indeterminate (D-I ). Normal lymph nodes characteristically present with central fatty hilum
(asterisk) and diffuse cortical thickening ≤ 3 mm. The indeterminate lymph nodes presented with
central hilum, however with some area with cortical thickening > 3 mm (between arrows). The A-
C lymph nodes demonstrated negative histopathological results, while the D-I lymph nodes were
positive.
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Sonographic images demonstrating some lymph nodes morphologically classified as suspicious.

The A-D lymph nodes present with marked cortical thickening, determining replacement and
marginalization of the fatty hilum (asterisks). In more advanced cases some lymph nodes may
present with total absence of the hilum (E,F)
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Breast MRI
Indications
1.Preoperative evaluation and staging of patients with newly diagnosed breast cancer.
2. Evaluation of breast cancer patients treated with neoadjuvant chemotherapy.
3. Evaluation of breast cancer patients with positive surgical margins following breast conservation
therapy.
4. Evaluation of patients with metastatic axillary lymphadenopathy and an unknown primary
malignancy.
5. Determination of silicone breast implant integrity.
6. Breast cancer screening in high risk women.
7. As a problem-solving tool for equivocal mammographic findings
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What are these images?

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