Mammography

 A mammogram is an x-ray picture of the

breasts. It is used to find tumors and to help
tell the difference between non-cancerous
(benign) and cancerous (malignant)
disease.
 Mammography uses low dose x-ray; high
contrast, high-resolution film; and an x-ray
system designed specifically for imaging the
breasts.
 Early detection of breast cancers.

 To help the radiologist or surgeon guide the

needle to the correct area in the breast
during biopsy.
 Anatomy
 The breast is a mass of glandular, fatty, and
fibrous tissues positioned over the pectoral
muscles of the chest wall and attached to
the chest wall by fibrous strands called
Cooper’s ligaments. A layer of fatty tissue
surrounds the breast glands and extends
throughout the breast. The fatty tissue gives
the breast a soft consistency.
 The breast is composed of:
 milk glands (lobules) that produce milk
 ducts that transport milk from the milk
glands (lobules) to the nipple
 nipple
 areola (pink or brown pigmented region
surrounding the nipple)
 connective (fibrous) tissue that surrounds
the lobules and ducts
 fat
 – Breast profile:
 A ducts
 B lobules
 C dilated section of duct to
hold milk
 D nipple
 E fat
 F pectoralis major muscle
 G chest wall/rib cage
 Schematic Diagram of the Female
Breast
                 
 Basic Physics of Mammography:
 X-ray images depend on differences in x-ray stopping
power (attenuation) to separate tissues. In general, a clear
separation between normal functioning tissue, and
abnormal cancerous tissues is not possible since their
attenuation if very similar. However both functional tissue
and cancer can be separated from fatty storage tissues
which normally surround active breast tissue, even in lean
persons. This is due to a substantially lower attenuation
caused by fat.

In older women, the functional glandular tissue diminishes,

leaving only thin supporting tissues clearly outlined by fatty
tissues. Mammography in these "mature" breasts is very
effective, since even small cancers are well outlined by fat.
In addition, many cancers develop calcium deposits which
strongly stop X-rays and are easily seen on mammograms.
 Basic Limitations of
Mammography:
 Since mammography cannot separate
normal gland tissue from tumors, it is much
more effective when gland tissue diminishes
with age. Many women retain glandular
tissue as they "mature", and it camouflages
tumors until they are large. As you might
expect, the young women's breast normally
contains more active tissue, which again
interferes with detection of small cancers.
 Types of Mammography

 Screening

 Diagnostic

 Ductgram/Galactogram (imaging the breast

ducts)
 Screening mammography
 Screening mammography is an x-ray examination
of the breasts in a woman who is asymptomatic
(has no complaints or symptoms of breast cancer).
The goal of screening mammography is to detect
cancer when it is still too small to be felt by a
woman or her physician. Early detection of small
breast cancers by screening mammography
greatly improves a woman's chances for
successful treatment. Screening mammography is
recommended every one to two years for women
once they reach 40 years of age and every year
once they reach 50 years of age. In some
instances, physicians may recommend beginning
screening mammography before age 40 (i.e. if the
woman has a strong family history of breast
cancer).
 Diagnostic mammography
 Diagnostic mammography is an x-ray examination
of the breast in a woman who either has a breast
complaint (for example, a breast lump or nipple
discharge is found during self-exam) or has had
an abnormality found during screening
mammography. It is more involved and time-
consuming than screening mammography and is
used to determine exact size and location of
breast abnormalities and to image the surrounding
tissue and lymph nodes. Typically, several
additional views of the breast are imaged and
interpreted during diagnostic mammography.
Thus, diagnostic mammography is more
expensive than screening mammography.
Mammography equipment
 How is Mammography
Performed?
 During mammography, the technologist will
position the patient and image each breast
separately. One at a time, each breast is
carefully positioned on a special film
cassette and then gently compressed with a
paddle (often made of clear Plexiglas or
other plastic). This compression flattens the
breast so that the maximum amount of
tissue can be imaged and examined.
 Cont…
 At some facilities, mammography technologists
may place adhesive markers to the breast skin
prior to taking images of the breast. The purpose
of the adhesive markers is twofold: first, to identify
areas with moles, blemishes or scars so that they
are not mistaken for abnormalities, and secondly,
to identify areas that may be of concern (e.g. a
lump was felt during physical examination). Some
centers routinely mark the nipple with a small dot
to provide a clear "landmark" for the radiologist on
the mammogram images.
 Breast compression is necessary in
order to:
 Even out the breast thickness so that all of the
tissue can be visualized.
 Spread out the tissue so that small abnormalities
are less likely to be obscured by overlying breast
tissue.
 Allow the use of a lower x-ray dose since a thinner
amount of breast tissue is being imaged.
 Hold the breast still in order to minimize blurring of
the image caused by motion.
 Reduce x-ray scatter to increase sharpness of
picture.
 Mammo app of normal breast
Different tissues in the breast absorb
different amounts of x-rays, producing
different shades of black, gray, and white on
the film:
 Fatty tissue absorbs a small amount of x-
rays and appears black or dark gray.
 Normal fibrous and glandular tissues (milk
glands, lymph nodes) contain water fluid
and absorb a moderate amount of x-rays,
and appear light gray.
 Fibrous and glandular tissues may contain
calcium and appear nearly white or white.
Breast comp & mammo app..
 Mammographic views

 Standard views

 Supplemental views
 Standard views

 CC (cranio-caudal) view

 MLO (medio-lateral oblique) view

 Supplemental Views

 Lateromedial, LM:
 Mediolateral view, ML
 Exaggerated cranial-caudal,
 Magnification views,
 Spot compression view
Mammographic views
Mediolateral Oblique View (MLO)
 The mediolateral oblique view (MLO) is
taken from an oblique or angled view.
During routine screening mammography,
the MLO view is preferred over a lateral 90-
degree projection because more of the
breast tissue can be imaged in the upper
outer quadrant of the breast and the axilla
(armpit).
 With the MLO view, the pectoral (chest)
muscle should be depicted obliquely from
above and visible down to the level of the
nipple or further down. The shape of the
muscle should curve or bulge outward as a
sign that the muscle is relaxed; the medial
(middle) portion of the breast should be
prominent in the MLO view. It is important
that compression be applied over the whole
image area. The nipple should be depicted
in profile and a small stomach fold should be
visible as a sign that the whole breast is
reproduced.
 Cranio-Caudal View (CC)
 The cranio-caudal view (CC) images the
breast from above. This view may be taken
during routine screening mammography and
during diagnostic mammography.
 With the CC view, the entire breast
parenchyma (glandular tissue) should be
depicted. The fatty tissue closest to the
breast muscle should appear as a dark strip
on the x-ray and behind that it should be
possible to make out the pectoral (chest)
muscle. The nipple should be depicted in
profile.
 Medio-Lateral View (ML)
 The medio-lateral view (ML) is taken from the
center of the chest outward. If no oblique
projection is taken, the mediolateral position may
be preferable to the latero-medial view (LM,
images the breast from the outer side of the breast
inward toward the center of the chest) since the
lateral side of the breast, where pathological
changes are most commonly found, is then closest
to the film. However, if the physician wants to
include as much of the medial side of the breast
as possible, the LM view may be chosen.
 With a lateral view, the pectoral (chest)
muscle should be depicted as a narrow light
band on at least half of the picture. The
nipple should be depicted in profile and a
clear stomach fold should be visible under
the breast.
 Latero-Medial View (LM)
 The latero-medial view (LM) images the
breast from its outer side toward the center
of the chest. When physicians want to
include as much of the medial portion of the
breast, the LM view may be used.
 Spot compression view
 also known as compression mammogram,
spot view, cone views, or focal
compression views. All mammograms
involve compression of the breast. Spot
views apply the compression to a smaller
area of tissue using a small compression
plate or cone. By applying compression to
only a specific area of the breast, the
effective pressure is increased on that spot.
This results in better tissue separation and
allows better visualization of the small area
in question.
 Spot compression view cont…
 Spot compression views show the borders
of an abnormality or questionable area
better than the standard mammography
views. Some areas that look unusual on the
standard mammography images are often
shown to be normal tissue on the spot
views. True abnormalities usually appear
more prominently and the margins (borders)
of the abnormality can be better seen on
compression views.
 Magnification views
 use a small magnification table which brings
the breast closer to the x-ray source and
further away from the film plate. This allows
the acquisition of "zoomed in" images (2
times magnification) of the region of interest.
Magnification views provide a clearer
assessment of the borders and the tissue
structures of a suspicious area, non
palpable lesion or a mass. Magnification
views are often used to evaluate micro-
calcifications, tiny specks of calcium in the
breast that may indicate a small cancer .
 Magnification views cont..
 Before performing a magnification view, the
mammographer must attach a firm, radiolucent
platform to the unit. This device allows the breast
to be elevated from the film, resulting in an
increased object-to-image distance (OID). The
platform may vary in height, depending on how
much the radiologist has chosen to magnify the
suspicious area. In addition, the standard
compression device is removed from the
mammography unit and replaced with a modified
compression paddle designed especially for
magnification views.
 Magnification views cont..
 Peak kilovoltage (kVp) is one factor that
must be considered. In elevating the breast,
a gap is produced between the breast and
the film. The space created reduces the
amount of scatter reaching the film, a
condition known as the air-gap effect. As a
result, a portion of radiographic density is
lost, and the kVp must be increased
accordingly to maintain an adequate
exposure.
 Magnification views cont..
 In addition to magnifying the object,
increasing OID also decreases geometric
sharpness. To correct this problem, a
smaller focal spot must be used. During
routine mammography, a .3 mm focal spot is
standard. During magnification
mammography, however, a .1 mm focal spot
is necessary to decrease the blurring that
results from image enlargement as well as
to increase recorded detail.
POSITIONING THE MAMMOGRAM
FOR VIEWING
 When viewing a mammogram it is important
to know the exact orientation of the image.
The breasts are best viewed as symmetric
organs.  Comparison of the right breast to
the left breast is done for evaluation of
symmetry.  The conventional method is to
evaluate mammograms in a mirror-like
fashion with both the MLO and CC views
mounted back to back.   
 Some radiologists mount the right
mammogram on the right and the left one on
the left.  Others prefer to view the
mammograms as if they were facing the
patient with the left breast on the observer's
right and the right breast on the observer's
left.  
 There are no hard-fast rules, and positioning
of mammograms on a viewbox is a matter of
individual preference.  Nonetheless, one's
approach should be systematic to avoid
mistakes. 
 Viewing the mammogram should proceed from a
distance to closer scrutiny of the particular
suspicious areas.  From a distance, the images
should be compared area for area, and the
respective regions of the left and right breasts
should look similar.  One should have both images
in view whereby the contour of the breast, the size
of the breast, and its symmetric density could be
evaluated.  This bird's eye evaluation for symmetry
is followed by a close-up individual view of each
image, looking for disruption in the "normal
pattern" of the breast such as abnormal densities,
areas of architectural distortion, masses and
calcifications. 
A magnifying lens may aid the viewer in his or her
search for suspected small masses and
microcalcifications or to clarify a small detail.
In some cases, a magnified mammographic view
can be taken to clarify the characteristics of a
suspected lesion.
 If there are prior mammograms available for
review, the individual breasts are evaluated
for changes over time.  The goal here is to
look for potential changes in asymmetric
density as well as to evaluate development
of new masses (neodensities) or new
calcifications. However, if the present study
is unremarkable, prior mammograms are of
lesser importance.
DEFINITION OF MAMMOGRAPHIC
LESIONS
 The sensitivity of mammography is initially determined by
the relative background composition of the breast
parenchyma. The denser the breast the less sensitive it is
to the detection of small masses, although small
calcifications can generally still be detected.
 The mammograms are initially evaluated for the presence
of
 masses,
 architectural distortion,
 asymmetric parenchyma,
 calcifications and
 skin changes
These mammographic findings are then further characterized and
compared to old studies, if available.
 Mammographicaly a
mass is defined as a space occupying
lesion seen in two different projections, with

density defined as a collection seen in only

one view.

A mass is then further characterized by it’s

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

characterizes the transition zone from mass

to surrounding parenchyma or fatty tissue.
The significance arises from the tendency of
invasive carcinoma to infiltrate adjacent
tissue and have indistinct, microlobulated or
frankly spiculated margins.
 Well circumscribed or sharply
marginated masses, either with or without
a radiolucent halo, are probably benign. If all
margins remain sharply circumscribed on
magnification views , and there is no associated
suspicious calcification, 98% to 99% will be benign
with a differential of fibroadenoma, cyst or
intramammary lumph node. When initially found
ultrasound to exclude a cyst is a very useful
adjuvant study. If the lesion is solid on ultrasound,
serial six month mammograms for two years would
be suggested, because of the low, 1-2%,
incidence of malignancy. An alternative to serial
imaging would be FNA or core needle biopsy.
 Circumscribed masses with irregular or
microlobulated margins on magnification
views should be considered suspicious and
biopsy suggested.
Similarly if the margins remain indistinct or
ill-defined on additional special views the
lesion must be considered suspicious and
biopsy considered.
Masses with spiculated margins
are suggestive of malignancy
With cancer, the spicules represent finger-
like projections of the malignant cells. Other
spiculated densities may represent radial
scar/sclerosising adenosis but are still
suspicious and can be associated with
tubular carcinoma. A spiculated density may
also be secondary to a post operative scar,
although the clinical history should provide
the clue and subsequent serial follow up
should demonstrate maturation and
involution or at least stability of the scar.
 Obscured Margins
(indeterminate, need further views): In this case, a
part of a mass is seen, part of the mass has a
circumscribed margin, but some or perhaps most
of the margin is covered by overlying tissue,
creating an indistinct margin. In this case, is is
frequently possible to move the extraneous tissue
using special views (focal compression view,
tissue roll view), which allow a completely
circumscribed (probable benign-watchful waiting)
margin to be seen. If a complete circumscribed
margin cannot be found, the mass must be
considered suspicious (consider biopsy)
 Margins
 The margin is the border of a mass, and it should
be examined carefully, sometimes using
magnification view for clarity. It is one of the most
important criteria in determining whether the mass
is likely to be benign or malignant. There are five
type of margins as defined by BIRADS:
 Circumscribed,
 Obscured,
 Micro-lobulated,
 Ill-defined, and
 Spiculated.
Circumscribed margins are well defined and
sharply demarcated with an abrupt transition
between the lesion and the surrounding tissue.
 Microlobulated margins have small
undulating circles along the edge of the
mass.
 Obscured margins are hidden by
superimposed or adjacent normal tissue.
 Ill-defined margins are poorly defined and
scattered.
 Spiculated margins are marked by
radiating thin lines. If there is no visible
mass, the basic description of architectural
distortion with spiculation as a modifier is
used.
 Density
 The density or degree of X-ray attenuation is defined relative
to the expected attenuation of an equal volume of normal
glanular tissue of the breast. It is important because most
breast cancers that form a mass appear to have attenuation
equal to or greater thatn the surrounding fibroglandular tissue.

Cancer shows high density because the cancer is firm and

resists being compressed as thinly as normal tissue, and thus
remains thicker and denser than surroundings, even with
focal compression views.
The tendancy to stand-out is may be helpful in finding the
tumor in a dense breast.
It is rare (though not impossible) for breast cancers to appear
as lower density. Breast cancers are never fatty (radiolucent)
in character, though they may trap fat. Central lucency is a
particularly useful sign or benign lymph nodes.
 The density catagories used are:
High density: clearly higher than surrounding,
suspicious.
Equal density: density not appreaciably different,
neutral significance.
Low density: density lower, but not fat containing,
neutral significance.
Fat containing: Radiolucent. This includes all
lesions containing fat such as oil cyst, lipoma,
galactocele, hamartoma or fibrolipoma. This is a
benign finding unless other characteristics are
suspicous.
 
 Location
 The location of the mass may be
established from the physical examination if
the mass is palpable. Otherwise, its location
can be determined from several different
mammographic views. It is important to
realize that the mass seen on a
mammogram may not correspond to a
palpable lump. Because breast cancer tends
to develop in the peripheral zone of the
breast's parenchymal cone, a mass' location
can raise suspicion of malignancy.
 Size

 Size alone does not predict malignancy.

Nonetheless, the size of a malignant mass
is indicative of its progression. The objective
of mammography is to detect breast cancer
in its earliest stage of development.
 Architectural Distortion
 Architectural distortion per se is not a mass. In this
class, the normal outline of tissues is distorted,
sometimes with no definable mass. It includes
spiculations (lines radiating from a center),
retraction (puckering) of normal connective tissue
lines.
It is a desmoplastic reaction in which there is focal
disruption of the normal breast tissue pattern.
Radiographically it appears as a distortion in which
surrounding breast tissues appear to be "pulled
inward" into a focal point. Often, it can be best
perceived at the interface between breast
parenchyma and subcutaneous and
retromammary fat.
 Architectural distortion can also appear within the
breast parenchyma itself, in which case it may be
best appreciated from a distance.

 It is important to do as many special view as needed

to establish the finding, as unexplained architectural
distortion usually merits biopsy even when no mass is
evident.

 While architectural distortion is a localizing sign of

cancer, a surgical scar, fibrocystic change, and in
some cases, the superimposition of breast tissues
may give the same appearance.
 Benign causes of architectual distortion
such as scarring tend to remain unchanged
or improve, so whenever previous
mammograms have been done, it is most
important to compare to see if changes have
really occurred.
 Evaluation of Associated
Structural Changes in the breast
 These are changes that may occur alone or more
commonly in the tissues surrounding masses or
calcifications. Many are suspicious in that they imply a
process which is infiltrating and altering the character
of adjacent tissues (1-6). Category 7 - Skin lesion is a
benign finding.
 1.) Skin retraction: The skin appears to be pulled or
tethered into an abnormality. This is a common finding
in more advanced infiltrative cancers, but can also
occur with scarring due to previous injury or biopsy. In
addition to a careful history to identify any previous
injury, previous mammograms can be very helpful if
they demonstrate the skin retraction is a long standing
finding due to scarring, and not a recent result of
infiltration.
 2.) Nipple retraction: The nipple is pulled in or
inverted. This can be seen as another sign of
advanced cancer infiltration, but is also a fairly
common observation in otherwise normal patients.
Previous studies documenting stability, and the
lack of an underlying mass are factors which can
reduce the concern regarding this finding. It is
important to exam the underlying area carefully
however to look for architectural distortion which
can indicate a tumor even in the absence of a
mass.
 3.) Skin thickening: When diffuse this is often
related to other systemic problems. When
localized, it may result from direct infiltration, or
tumor blockage of local lymphatic drainage. As
with 1 and 2, the absence of change, and the
absence of an associated mass reduce the
importance of this finding.
 4.) Trabecular thickening: This is focal thickening
of fibrous septae in the breast. It raises question of
infiltration particularly in association with mass.
  5.) Axillary Adenopathy: Enlarged non-fatty lymph
nodes in the axilla may be commented on.
Because the enlargement may be due to
inflammatory involvement in the upper extremity or
breast, attributing enlargement to breast
malignancy is often unreliable.
 6.) Architectural Distortion: When disturbance in
the course and shape of the normal trebecular
architecture is seen, particularly if it persists with
directed focal compression views, the possibility of
infiltration should be entertained. This is a finding
in itself if no mass is seen, and is a associated
finding when distorted or retracted tissues are
seen surrounding a mass or other finding.
 7.) Skin Lesion: This is a mammographic finding
projects from skin over breast in two views. It is
almost never associated with breast cancer, but
may simulate a mass. Careful positioning with
special tangential views are used to prove the
benign skin location.
diffuse skin thickening
 CALCIFICATIONS
 Calcifications are often important and common
findings on a mammogram. They can be produced
from cell secretion or from necrotic cellular debris.
They may be intramammary, within and around
the ducts, within the lobules, in vascular
structures, in interlobular connective tissue or fat.
Alternatively, they may be found in the skin. They
can appear with or without an associated lesion,
and their morphologies and distribution provide
clues as to their etiology as well as whether they
can be associated with a benign or malignant
process.
 Calcifications found with a mass provide
further information about that particular
mass. For example, an involuting
fibroadenoma will often contain popcorn-like
macrocalcifications. Similarly, fine
curvilinear calcifications at the margin (i.e.
rim calcifications) of a round or oval mass
indicate a benign process. On the other
hand, a mass with pleomorphic, irregularly
shaped calicifications heterogeneous in size
and morphology raises much greater
concern about malignancy.
 Calcifications are analyzed according to
their size, shape, number, and distribution.
The general rule is that larger, round or oval
shaped calcifications uniform in size has a
higher probability of being associated with a
benign process and smaller, irregular,
polymorphic, branching calcifications
heterogeneous in size and morphology are
more often associated with a malignant
process. Certain calcification patterns are
almost always pathognomic of a benign
process, and in such cases no further
analysis is needed.
 In the majority of cases, however, a pattern
of calcification deposition is inconclusive
and may be attributable to either a benign or
malignant process. Needless to say, these
cases require additional evaluation such as
using magnification mammography to
further elucidate the calcifications'
morphology and distribution.
 Size
 Generally speaking, microcalcifications are
associated with a malignant process and
macrocalcifications are associated with a benign
process. The problem with this general rule is that
there is no fine line of measurement that could
enable one to distinguish between micro and
macro. All calcifications start out imperceptably
small and radiographically invisible. Most
radiologists place calcifications 0.5 mm or less to
have a high probability of association with cancer;
and calcifications of 2.0 mm or larger are typical of
a benign process. The smallest visible
calcifications on a mammogram is approximately
0.2 - 0.3 mm.
 Number
 The number of calcifications that make up a
cluster has been used as an indicator of benign
and malignancy. While the actual number itself is
arbitrary, radiologists tend to agree that the
minimum number of calcifications be either four,
five, or six to be of significance. Any number of
calcifications less than four will rarely lead to the
detection of breast cancer in and of itself. Again,
as with all criteria in mammographic analysis, no
number is absolute and two or three calcifications
may merit greater suspicion if they exhibit
worrisome morphologies.
 Morphology
The morphology of calcifications is considered to
be the most important indicator in differentiating
benign from malignant. As noted earlier, round
and oval shaped calcifications that are also
uniform in shape and size are more likely to be on
the benign end of the spectrum. Calcifications that
are irregular in shape and size fall closer to the
malignant end of the spectrum. It has been
described that calcifications associated with a
malignant process resemble small fragments of
broken glass and are rarely round or smooth.
 Distribution
Distribution modifiers (grouped or clustered,
linear, segmental, regional, diffuse) are used to
describe the arrangement of the calcifications.
 Grouped or clustered should be used to describe
calcifications that occupy a small volume (<2 µL)
of tissue.
 Calcifications that are linearly distributed are
arranged in a line and may have branch points.
 Segmentally distributed calcifications suggest
deposition of calcification in a duct and its
branches. This type of calcification may be
secondary to benign or malignant processes.
 Regionally distributed calcifications are most
likely due to benign processes. These
calcifications are scattered in a large volume
of the breast and do not necessarily conform
to a ductal distribution.
 Diffusely distributed calcifications are
scattered randomly throughout the breast.
 Benign Calcifications
 Skin or dermal calcifications
are usually identified as spherical, lucent-centered
calcifications at the periphery of the breast,
especially in the inferior, posterior, and medial
Usually, skin calcifications are readily
distinguished as benign findings. However, in
some cases, additional imaging is needed to
differentiate skin calcifications from more
worrisome calcifications.
When mammograms are compared, calcifications
that maintain a fixed relationship to one another
are suggestive of a dermal location. Magnification
views may be used to demonstrate the lucent
centers characteristic of skin calcifications.
 Vascular calcifications
are commonly identified on mammography,
especially in older women. Vascular calcifications,
which are usually secondary to medial
atherosclerosis, often demonstrate a characteristic
train tracklike configuration. In some cases, it may
be difficult to distinguish vascular calcifications
from ductal calcifications (including calcifications
representing ductal carcinoma in situ). Arterial
calcification in the breasts may be associated with
diabetes and hyperparathyroidism.
 Lucent-centered calcifications
which are round or oval, are almost always
benign and they have thicker walls than
those of rim or eggshell calcifications. Skin
calcifications are often lucent-centered, and
lucent-centered calcifications may form
around benign debris in the ducts. Other
entities that may appear as lucent-centered
calcifications on mammography include
silicone granulomas and fat necrosis
 Eggshell or rim calcifications
are thin and appear as calcium deposited on the
surface of a sphere. The walls of eggshell or rim
calcifications are thinner than the walls of lucent-
centered calcifications.
The entire circumference of an eggshell
calcification does not need to be completely
calcified to represent a benign finding. Although fat
necrosis can result in eggshell calcifications,
calcification in the walls of cysts is the most
common cause of eggshell or rim calcifications.
 Coarse or popcorn like calcifications
are associated with the involution and
hyaline degeneration of fibroadenomas.
Fibroadenomas are the most common
breast masses seen in women younger than
35 years of age.
Calcifications in fibroadenomas usually
begin at the periphery and then involve the
central portion of the fibroadenoma.
Fibroadenomas may be completely replaced
by calcification without a mass discernible
by mammography.
 Large rodlike, or secretory calcifications
are oriented along the axes of the ductal system.
These calcifications result from calcification of
ductal secretions. Large rodlike calcifications may
have lucent centers if the ductal secretions
undergo peripheral calcification. In general, these
calcifications are coarser and larger (usually > 1
mm in diameter) than malignant calcifications.
Large rod like calcifications are commonly bilateral
and diffuse. These calcifications are associated
with secretory disease, plasma cell mastitis, and
duct ectasia.
 Round and punctate calcifications
Punctate calcifications are spherical
calcifications that have well-defined
margins.They usually measure less than 0.5
mm in diameter.
Round calcifications are benign spherical
calcifications that may vary in size. When
less than 1 mm, round calcifications are
frequently formed in the acini of the lobules.
Suture calcifications
Suture material may become calcified,
resulting in suture calcifications.20,21
Suture calcifications are usually seen at a
known surgical site, and the calcifications
may be linear or tubular. Knots may be
demonstrated. Suture calcifications are
likely due to delayed resorption of catgut
sutures, which can provide a matrix on
which calcium can precipitate.
 Calcifications that are of
intermediate concern
 Amorphous calcifications: These are very
tiny, hazy calcifications and are often difficult
to pick up on CR machines
 Calcifications that are highly
suspicious for malignancy
 Fine, linear, branching or casting
calcifications:
These are linear, rod-like calcifications and
are typically seen in malignancy
 Pleomorphic calcifications:

These are microcalcifications of varying

shapes and sizes
 ASYMMETRIC DENSITY
 The breasts are seen as symmetric
structures and should be compared as such.
An asymmetric area may be indicative of a
developing mass, a variation of normal
breast tissue, postoperative change from a
previous biopsy, or merely poor positioning
and compression during imaging. The
appearance of asymmetries due to
positioning and compression during imaging
is often the result of superimposition of
normal breast structures.
 True breast asymmetry, on the other hand, is
three-dimensional and should be present on both
MLO and CC views. Once an asymmetry is
determined to be real, the interpreter must
determine whether the asymmetry is a benign
variation of asymmetric breast tissue or a focal
asymmetric density that may represent a
significant mass. If the former determination could
not be made, further evalution is necessary to
clarify if the focal asymmetric density may possibly
be a malignant process.
 ASSESSMENT CATEGORIES

 Category 0 / Need Additional Imaging Evaluation

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

 Category 1 / Negative
There is nothing to comment on. The breasts are
symmetrical and no masses, architectural disturbances or
suspicious calcifications are present
 Category 2 / Benign Finding
This is also a negative mammogram, but the
interpreter may wish to describe a finding.
Involuting, calcified fibroadenomas, multiple
secretory calcifications, fat containing lesions such
as oil cysts, lipomas, galactoceles, and mixed
density hamartomas all have characteristic
appearances, and may be labeled with
confidence. The interpreter might wish to describe
intramammary lymph nodes, implants, etc. while
still concluding that there is no mammographic
evidence of malignancy.
 Category 3 / Probably Benign Finding - Short
Interval Follow-Up Suggested
A finding placed in this category should have a
very high probability of being benign. It is not
expected to change over the follow-up interval, but
the radiologist would prefer to establish its
stability. Data are becoming available that shed
light on the efficacy of short interval follow-up. At
the present time, most approaches are intuitive.
These will likely undergo future modification as
more data accrue as to the validity of an approach,
the interval required, and the type of findings that
should be followed.
 Category 4 / Suspicious Abnormality - Biopsy
Should Be Considered
These are lesions that do not have the
characteristic morphologies of breast cancer but
have a definite probability of being malignant. The
radiologist has sufficient concern to urge a biopsy.
If possible, the relevant probabilities should be
cited so that the patient and her physician can
make the decision on the ultimate course of
action.
 Category 5 / Highly Suggestive of Malignancy -
Appropriate Action Should Be Taken
These lesions have a high probability of being
cancer
 Category 6: Biopsy proven malignancy
 Digital Mammography
 One of the most recent advances in x-ray
mammography is digital mammography. Digital
(computerized) mammography is similar to
standard mammography in that x-rays are used to
produce detailed images of the breast. Digital
mammography uses essentially the same
mammography system as conventional
mammography, but the system is equipped with a
digital receptor and a computer instead of a film
cassette. Several studies have demonstrated that
digital mammography is at least as accurate as
standard mammography.
 How Does Digital Mammography
Differ From Standard Mammography?
 In standard mammography, images are recorded
on film using an x-ray cassette. The film is viewed
by the radiologist using a "light box" and then
stored in a jacket. With digital mammography, the
breast image is captured using a special electronic
x-ray detector, which converts the image into a
digital picture for review on a computer monitor.
The digital mammogram is then stored on a
computer. With digital mammography, the
magnification, orientation, brightness, and contrast
of the image may be altered after the exam is
completed to help the radiologist more clearly see
certain areas.
 Digital mammography may provide additional
benefits, such as lower radiation doses and higher
sensitivity to abnormalities.
 The use of digital mammography can lead to fewer
"recalls" (repeat mammograms) than film
mammography.
 Other data from German researchers suggest that
the radiation dose can be reduced by up to 50%
with digital mammography and still detect breast
cancer as well as the standard radiation dose of
film mammography.
 Digital mammography systems cost approximately
1.5 to 4 times as much as standard film
mammography systems.
 While procedural time saved by using digital
mammography over standard film mammography
justifies part of the cost for facilities that perform
several thousand mammograms each year, the
study will determine whether the high cost of
digital mammography is justifiable in terms of its
benefits in detecting breast cancer.
 From the patient's perspective, a digital
mammogram is the same as a standard film-based
mammogram in that breast compression and
radiation are necessary to create clear images of
the breast.
 The time needed to position the patient is the
same for each method. However, conventional film
mammography requires several minutes to
develop the film while digital mammography
provides the image on the computer monitor in
less than a minute after the exposure/data
acquisition. Thus, digital mammography provides a
shorter exam for the woman and may possibly
allow mammography facilities to conduct more
mammograms in a day.
 Digital mammography can also be manipulated to
correct for under or over exposure after the exam
is completed, eliminating the need for some
women to undergo repeat mammograms before
leaving the facility.
 With digital mammography, the
magnification, orientation, brightness, and
contrast of the mammogram image may
also be altered after the exam is completed
to help the radiologist more clearly see
certain areas of the breast.
 In the near future, digital mammography may
provide many benefits over standard film
mammography. These benefits include:
 Improved contrast between dense and non-dense
breast tissue
 Faster image acquisition (less than a minute)
 Shorter exam time (approximately half that of film-
based mammography)
 Easier image storage
 Ability to correct under or over-exposure of films
without having to repeat mammograms
 Transmittal of images over phone lines or a
network for remote consultation with other
physicians
 According to one study results, digital and standard
film mammography had similar accuracy rates for
many women. However, digital mammography was
significantly better at screening women in any of the
following categories:
 under age 50, regardless of what level of breast tissue
density they had
 of any age with very dense or extremely dense
breasts
 pre- or perimenopausal women of any age (defined as
women who had a last menstrual period within 12
months of their mammograms)
 The study showed no benefit for post-menopausal
women over age 50 who did not have dense breast
tissue.
 Disadvantages to Digital Mammography
While digital mammography is quite promising, it still has
additional hurdles to undergo before it replaces
conventional mammography. Digital mammography must:
 provide higher detail resolution (as standard
mammography does)
 become less expensive (digital mammography is currently
several times more costly than conventional
mammography)
 provide a method to efficiently compare digital
mammogram images with existing mammography films on
computer monitors
 Standard mammography using film cassettes has the
benefit of providing very high detail resolution (image
sharpness), which is especially useful for imaging
microcalcifications (tiny calcium deposits) and very small
abnormalities that may indicate early breast cancer.
 The high cost of digital mammography is a major obstacle.
 Sonomammography
1. Equipment requirements

Linear array or annular array transducer

configurations are suitable for high quality images.
The dominant transducer frequency should be 7.5
MHz or higher, preferably of a broad bandwidth
construction .
However, high frequency on its own is not a
sufficient parameter to ensure quality.
A penetration depth of at least 4 cm with
selectable focal regions is required.
 A field of view greater than 4 cm is
preferable for large area examinations, and
smaller fields are suitable for detailed
examination of specific findings.
2. Examination technique
In order to evaluate breast anatomy and
not to miss subtle pathology, the
examination should be:-
 Systematic
 Comprehensive
 Reproducible
 Systematic
1. A planned approach for performance and
documentation of the examination is
required.
2. When a specific lesion is examined, its
precise position should be noted on the
image and its correlation with the clinical
and mammographic findings recorded.
3. When the total breast volume needs to be
assessed, overlapping scans will ensure
complete examination. 
 comprehensiveAll breast structures must
be completely displayed, and particular care
taken in the area of interest to ensure that
normal anatomical and/or pathological
findings are recognized and recorded. 
 reproducibleThe imaging results must be
readily reproducible, and ultrasonic findings
should be clearly identified on the stored
images. It should be possible to confirm the
same appearances on different types of high
resolution ultrasonic scanning systems. 
 As the acquisition of ultrasonic images is very
operator dependent, a thorough understanding of
the physical principles of ultrasound and of the
normal anatomy are essential to achieve high
quality images.
 Supine oblique or supine position is recommended
to reduce breast thickness and to improve
visualization of deeper tissues. The reduced
thickness allows optimization of focusing.
 One or both arms should be elevated behind the
head or neck to stretch the pectoralis muscle for
better fixation and immobilization of the breast.
 When scanning, the transducer should always be
perpendicular to the skin surface.
 Transducer coupling to the skin surface should be
gentle and should give complete contact.
 Strong compression pushes lesions out of the
scanning plane below the transducer and should
be avoided as it deforms tissue structures making
interpretation more difficult.
 Compression is useful to avoid refraction and
scattering from normal anatomical structures when
sound penetration is insufficient, and to examine
tissue elasticity of benign and malignant findings.
 The scanning procedure should involve
overlapping scanning planes. These may be
parasagittal, transverse, radial, or antiradial.
Radial and antiradial scans follow normal
anatomical patterns, assisting the
recognition of abnormalities and better
demonstrating ductal structure and changes.
 3. Interpretation
 Ultrasonic examination of the breast is
difficult and requires:-
a) Detailed knowledge of anatomy,
physiological changes and benign and
malignant pathology.
b) Correlation of findings with other imaging
results, clinical information and examination.
Imaging features to be assessed:
Lesion features Adjacent features
Shape (including Architectural
depth/width ratio)  pattern 
Boundaries/margins Fibroglandular
(including edge echogenicity 
refraction) 
Internal echo Fat echogenicity 
texture 
Through Cooper's ligament
transmission thickness 
(enhancement,
shadowing) 
Lesion features Adjacent features

Calcifications  Skin thickness 

Ductal alterations
 The minimum report should include:
 The indications for the examination
 A description of any lesion(s) and adjacent
features including the size of maximum
diameter(s) or extent
 The position of the lesion(s) as represented on a
clock face with its distance from the nipple
 Correlation with clinical and/or mammographic or
other imaging findings
 Opinion regarding provisional diagnosis(es) and
significance of finding(s)
 4. Interventional procedures
 Guided interventional procedures include:-
1) Cytology and core biopsy
2) Abscess drainage
3) Preoperative localization: hookwire placement,
carbon tracking, and radionuclide marking
4) Intraoperative localization or localization
5) Radionuclide injection for sentinel node
identification
6) Specimen imaging for verification of lesion
removal
 5. Accuracy and confidence.
 Accuracy and confidence in interpretation
requires experience.
 Continuous education and follow up are
essential to improve and maintain skills in
technique and interpretation.
Normal breast parenchymal patterns
Breast ultrasound: criteria for benign
lesions
 Smooth and well circumscribed
 Hyperechoic, isoechoic or mildly
hypoechoic
 Thin echogenic capsule
 Ellipsoid shape, with the maximum
diameter being in the transverse plane
 Three or fewer gentle lobulations
 Absence of any malignant findings
 Breast cysts
 Breast cysts are the commonest cause of breast
lumps in women between 35 and 50 years of
age.A cyst occurs when fluid accumulates due to
obstruction of the extralobular terminal ducts,
either due to fibrosis or because of intraductal
epithelial proliferation. A cyst is seen on USG as a
well-defined, round or oval, anechoic structure
with a thin wall .They may be solitary or multiple.
Complex cyst: When internal echoes or debris are
seen, the cyst is called a complex cyst. These
internal echoes may be caused by floating
cholesterol crystals, pus, blood or milk of calcium
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
 This lesion has a variable appearance.
Typically, duct ectasia may appear as a
single tubular structure filled with fluid or
sometimes may show multiple such
structures as well. Old cellular debris may
appear as echogenic content. If the debris
fills the lumen, it can be sometimes
mistaken for a solid mass, unless the tubular
shape is picked up.
Longitudinal image (A) shows a dilated duct containing inspissated debris
(arrow) is seen. In crosssection (B), the intraductal debris may appear as

a focal lesion (arrowheads)

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

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

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

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

 Characteristics of malignant lesions
 Malignant lesions are commonly hypoechoic
lesions with ill-defined borders. Typically, a
malignant lesion presents as a hypoechoic nodular
lesion, which is ‘taller than broader’ and has
spiculated margins, posterior acoustic shadowing
and microcalcifications. The spiky extensions
along the tissue planes can be well seen in
coronal images .It was initially believed that color
Doppler scanning would add to the specificity of
USG examination, but this has not proven to be
very efficacious; however, in certain situations it
does help resolve the issue, particularly when
there is significant vascularity present within highly
cellular types of malignancies
 Breast MRI
(MR mammography) Magnetic resonance
imaging of the breast is particularly useful in
evaluation of newly diagnosed breast
cancer,
 in women whose breast tissue is
mammographically very dense and for,
 screening in women with a high lifetime risk
of breast cancer because of their family
history or genetic disposition.
 Breast MRI can be performed on all
standard whole body magnets at a field
strength of 0.5 T - 1.5 Tesla.
 The use of a dedicated bilateral breast coil
is obligatory.
 Breast cancer is detectable due to the
strong enhancement in dynamic breast
imaging that peaks early (about 1-2 min)
after contrast medium injection. If breast
cancer is suspected, a breast biopsy may
be necessary to secure the diagnosis.
 Requirements in breast MRI
procedures:
 Both breasts must be measured without gaps.
 Temporal resolution should be sufficient to allow
early imaging after contrast agent with dynamic
imaging every 60-120 sec.
 For the best possible detection of enhancement fat
signal should be eliminated either by image
subtraction or by spectrally selective fat saturation.
 Thin slices are necessary to assure absence of
partial volume effects.
 Imaging should be performed with a spatial
resolution in plane less than 1 mm.
T2 weigthed MR image of both
breasts. 
T1 weighted MR image of both
breasts.
T1 weighted MR image of the
breasts. 
T1 weighted MR image of both
breasts with contrast.