BREAST ANATOMY
THE BREAST
• Conical, round, or hemispherical shape
• Comprised of 15-20 lobes, each encased
in fascial sheath defined by AMF & PMF
• Extends from 2nd or 3rd intercostal space
to 6th or 7th intercostal space
• Extends laterally to anterior axillary fold
and medially to lateral sternum
• Relationship to chest wall
-the superior two-thirds overlies
pectoralis major muscle
-lateral portions overlie serratus anterior
muscle
-inferior-most margin overlies upper
abdominal oblique muscles
• Axillary tail of spence: extension of
normal breast tissue toward axilla
• Average breast size: diameter 10-12 cm;
thickness 5-7 cm; median 5 cm thick with
mammographic compression
• Support and mobility relate to fascial
attachments to skin and chest wall
FEMALE VS. MALE
Female breast
• the mature female breast has a prominent
ductal network that ends in terminal
mammary lobules
• Has abundant adipose and stromal tissue.
• Presence of Cooper’s ligaments that
support the entire structure.
Male breast
- Primarily made up of adipose tissue,
- consists of a vestigial ductal network devoid of
mammary lobules
- Small nipple-areolar complex.
- Cooper’s ligaments are absent in the male breast
- The pectoral muscle is more prominent.
EXTERNAL ANATOMY
GROSS ANATOMY
• Upper and medial aspect
- Skin surface smoothly transitions
to chest wall
• Inferior aspect
- Skin surface smoothly transitions
to upper abdominal skin
• Lateral aspect
- Margin of breast clearly defined
from chest wall and axillary tissues
NIPPLE-AREOLAR COMPLEX
• Highly pigmented
• Subareolar smooth muscle arranged
radially and circumferentially
-Expedites nipple erection during nursing
• Increases in pigmentation and size during
puberty
• Further increases in size and
pigmentation during pregnancy
NIPPLE
• Projects at level of 4th intercostal space in
non-pendulous breast
• Conical shape with average height of 10-
12 mm
• 8-12 major duct orifices at bases of
crevices on nipple surface
• Subdermal smooth muscle present to
facilitate nipple function during nursing
AREOLA
• Circular and pigmented area, measuring
15-60 mm in diameter
• Contents
- Apocrine sweat glands
- Sebaceous glands
- Hair follicles
- Accessory areolar glands (of
Montgomery)
• Areolar dermis contains smooth muscle
in contiguity with nipple smooth muscle
MONTGOMERY'S GLANDS - large sebaceous
glands capable of secreting milk; they represent
an intermediate stage between the sweat and the
mammary glands.
MORGAGNI'S TUBERCLES - located near the
periphery of the areola, are elevations formed by
the openings of the ducts of Montgomery’s glands.

SKIN
• Average thickness 0.5-2 mm
• Contents
- sweat glands
- sebaceous glands
- hair follicles
AXILLARY TAIL
• A.K.A "axillary tail of spence”
• The prolongation of upper outer quadrant
of the breast in the axillary direction.
Once it passes through the foramen of
langer, it pierces the axillary fascia. The
duct system is seen to extend into the
axilla.
INFRAMAMMARY FOLD (IMF)
-A zone of adherence of the superficial fascial
system to the underlying chest wall. It is
anatomically defined as the area where the
skin of the lower pole of glandular breast
tissue meets the chest wall forming a groove
known as the inframammary crease.
INTERNAL ANATOMY OF THE BREAST
FASCIAL LAYERS
The breast tissue is encircled by a thin layer
of connective tissue called fascia. The deep
layer of this fascia sits immediately atop the
pectoralis muscle, and the superficial layer
sits just under the skin.
RETROMAMMARY SPACE
• In reality this is not a space but a plane of
loose connective tissue lying between the
deep lamina of the superficial fascia and the
deep pre-pectoral fascia.
• This is the plane of dissection in which a sub
glandular pocket can be created for insertion
of a prosthesis for breast augmentation.
DUCTS AND LOBULES
• The breast is composed of approximately 15
to 20 lobes and these lobes are further
divided into lobules. The lobules are made up
of branched alveolar glands. Each lobe drains
into a major lactiferous duct.
• Lactiferous ducts - dilate into a lactiferous
sinus beneath the areola and then open
through a constricted orifice onto the nipple.
• Terminal end buds - formed during the
development of the breasts at the time of
puberty wherein the ducts grow and divide.
Alveolar buds – branches and small ductules
formed by then terminal end buds
*Alveolus- sometimes refers to the end secretory
unit at rest or nonpregnant state
*Acini - refers to the fully developed unit in
pregnancy or lactation.
STROMA AND CONNECTIVE TISSUE
• Fat
• Cooper’s ligament
• Nerves, blood vessels and lymphatics
FAT/ADIPOSE TISSUE
- collection of fat cells
- extends from the collarbone down to the
underarm and across to the middle of the
ribcage.
- As a woman ages, especially once she reaches
menopause, the breast tissue contains more
adipose (fatty) tissue.
COOPER’S LIGAMENTS
- the fibrous connections between the
inner side of the breast skin and the pectoral
muscles. Working in conjunction with the fatty
tissues and the more fibrous lobular tissues, they
are largely responsible for maintaining the shape
and configuration of the breast.
NERVE SUPPLY FOR THE BREAST
• Facilitate nipple erection
• Allow flow of milk during suckling
• Sympathetic fibers to skin and breast
tissue modulate blood flow
• Affect apocrine function
Three major groups innervate breast and
converge on nipple-areolar complex
- supraclavicular nerves via cervical plexus
- thoracic nerve branches via brachial plexus
- intercostal nerves
ARTERIES
• Consists of vessels that enter via
superolateral, superomedial and deep
aspects of breast
• Multiple small perforating branches and intra
mammary anastomoses
Internal mammary (thoracic) artery
• Supplies approximately 60% of breast medially
and centrally
• Originates from subclavian artery
• Descends along lateral surface of sternum
• Anterior perforating branches pass through
2nd-4th intercostal spaces and become medial
mammary arteries
LATERAL THORACIC ARTERY
• supplies approximately 30% of breast,
primarily upper outer quadrant
• origin
- most commonly arises from axillary artery
- less commonly arises from thoracoacromial or
subscapular
Artery
- descends along axillary border of
pectoralis minor muscle
• Provides multiple lateral mammary branches
• 3rd, 4th, and 5th posterior intercostal arteries
- lateral mammary branches of lateral cutaneous
branches
• Pectoral branch of thoracoacromial artery
• Subscapular artery
• Thoracodorsal artery
VENOUS DRAINAGE
• Multiple potential pathways for
hematogenous metastases from breast
cancer
• Lymphatic drainage pathways may parallel
venous drainage
• Superficial systems
• Usually do not accompany arteries
• Form anastomotic circle near nipple-areolar
complex (circulus venosus)
• Drain to periphery of breast and join deep
venous system
DEEP SYSTEMS
• May provide direct pathways for metastatic
disease to lung
• Generally, accompany arteries supplying
region of breast
• Three principal routes of deep venous
drainage
-posterior intercostal vein branches
-axillary vein branches
-internal mammary vein branches
VERTEBRAL PLEXUS (BATSON PLEXUS)
• Composed of valveless venous channels
• Surrounds vertebral column extending
from skull to sacrum
• In contiguity with posterior intercostal
vessels
• Potential route for hematogenous
metastases from breast cancer to spine,
ribs and brain
MUSCULATURE
Pectoralis major
• located immediately deep to superior 2/3 of
breast tissue
• smaller clavicular division originates from
medial half of clavicle
• larger costosternal division originates from
sternum and 2nd-6th costal cartilages
• inserts into greater tuberosity of humerus
• innervated by medial and lateral pectoral
nerves from brachial plexus
• cephalic vein separates lateral border from
deltoid muscle
Pectoralis minor
• located deep to the pectoralis major
• origin from 2nd-5th ribs
• inserts into coracoid process of scapula
• innervated by medial pectoral nerve arising
from medial division of brachial plexus
• important landmark for zonal lymph node
pathology
LYMPH NODES AND LYMPHATICS
• 75% of drainage is via lateral and medial
trunks
• Extending from areola to axilla
-axilla drains to subclavian lymphatic trunk
• 25% of lymphatic drainage is via internal
mammary nodes
MAJOR LYMPH NODE GROUPS
Axillary lymph nodes
Axillary vein group
- most lateral group
- lies medial and posterior to axillary vein
- consists of 4-6 nodes
Pectoral (anterior) group
- projects at inferior margin of pectoralis minor
muscle
- receives majority of breast lymphatic drainage
- drains primarily into central lymph node group
but may drain directly into sub clavicular group
- consists of 4-5 nodes
Scapular (subscapular) group
- projects near posterior margin of axilla and
lateral margin of scapula
- receives additional lymph flow from posterior
neck, trunk, and shoulder
- drains into central and subclavicular groups
- consists of 5-7 nodes
Central group
- projects in axillary fat deep/posterior to
pectoralis minor muscle
- drains to apical and infraclavicular groups
- most superficial and most easily palpable of
axillary nodal groups
- consists of 3-4 nodes
INTERPECTORAL (ROTTER) GROUP
- between pectoralis major and pectoralis minor
muscles
- drains into central and subclavicular groups
- consists of 1-4 nodes
Subclavicular (apical) group
- medial and posterior to pectoralis minor
muscle at apex of axilla
- may be final common pathway of lymphatic
drainage for all other
Axillary groups
- efferent lymphatics may join thoracic duct,
internal jugular vein, subclavian vein or pass to
deep cervical nodes
- consists of 6-12 nodes
Internal mammary (parasternal) nodes
• located in parasternal intercostal spaces;
< 6 mm in diameter
• Predominantly drain far medial and deep
medial breast
• Nodes in 1st-3rd intercostal spaces may
be affected in metastatic breast cancer
SURGICAL LYMPH NODE LEVELS
LEVEL I
- lymph nodes lateral/inferior to pectoralis
minor muscle
- includes scapular, axillary vein and pectoral
groups
LEVEL II
- lymph nodes deep/posterior to pectoralis
minor muscle
- includes central and interpectoral groups and
possibly portions of subclavicular group
LEVEL III
- lymph nodes medial and superior to pectoralis
minor muscle
- includes primarily subclavicular group
• Sentinel node evaluation:
- one to a few lower level I nodes
• Surgical axillary dissection:
- level I and II nodes
Intramammary lymph nodes
- 25-28% of normal women have intra mammary 2. NEONATAL
lymph nodes visible on mammography • Connective tissue proliferates causing
- Can occur anywhere: most common in far nipple to become erect
lateral, axillary, and posteromedial aspects of • Hormonally stimulated lobular tissue may
breast secrete
- May be difficult to surgically distinguish
intra mammary lymph node in axillary tail from 3. CHILDHOOD AND PUBERTY
axillary lymph node • Main ducts branch; give rise to
terminal buds, precursors of terminal ductal
lobular units (TDLUs)
• Adipose cells proliferate, enlarge
and extend into subcutaneous tissue
• Periductal tissues (stroma)
increase: blood vessels proliferate

LESSON 2
Developmental stages of the BREAST
1. FETAL/ EMBRYOLOGY
• Weeks 4-6
- ectodermal streaks develop from fetal axilla to
groin
• Weeks 6-8
- mammary ridges involute
- invagination of chest wall mesenchyme TANNER PHASES OF PUBERTAL BREAST
• Weeks 12-16 DEVELOPMENT
- differentiation of smooth muscle of nipple and I: Nipple elevation starts but no palpable
areola glandular elements (after
- development of epithelial buds and bud the 8th birthday)
branching II: Nipple and breast project as mound from
•Weeks 16-20 chest wall with palpable
- development of hair follicles, apocrine tissue in subareolar region (from age 9 11)
glands and glands of Montgomery III: Increased glandular tissue/increased areolar
- appearance of primitive elements of size and pigmentation
breast parenchyma (After age 12)
• 3rd trimester IV: Development of separate nipple-areolar
- epidermis depresses into shallow mammary pit complex as secondary
- nipple-areolar complex enlarges and develops mound anterior to breast (around age 13)
pigmentation V: Final adolescent development with smooth
- main ducts canalize breast contour (around age 15)
- lobules begin differentiation
4. MENSTRUATION
Proliferative phase (follicular phase of ovary)
- Days 3-14 of menstrual cycle
- Overall regression of breast epithelium
- Increase in ovarian estrogen production under
pituitary control
- Stroma becomes less dense
- Duct lumens expand with increased epithelial
cell activity
- Lowest breast volume and water content

Secretory phase (luteal phase of ovary)

Days 15-28 of menstrual cycle
- Stromal density increases
- Ductal epithelium proliferates
- Water content of breast increases
- Clinical symptoms relate to increased
interlobular fluid
- Generalized lobular proliferation LESSON 3: BREAST ANOMALIES

5. PREGNANCY 1. ASYMMETRY IN BREAST SIZE

Marked ductal and lobular proliferation in early • POSSIBLE CAUSES:
weeks of pregnancy - Developing occult malignancy
•Weeks 5-9 - Normal variant
- Generalized breast enlargement - Post radiation hypoplasia of the breast
- Progressive increase in nipple-areolar complex - Post surgical breast:
pigmentation lumpectomy on the smaller side
•Second half of pregnancy - Previous chest wall trauma
- Progressive lobular proliferation - Congenital
- Stromal and fat elements increase - Poland Syndrome
- Colostrum accumulates in alveoli Ex. of breast showing symmetry with similar
architecture
6. LACTATION
• Immediate post-partum enlargement due to
colostrum accumulation
• Milk secreted into alveoli 3-7 days post partum
• Post-lactational changes
- increase in periductal and perivascular stromal
connective tissue Ex. of breast asymmetry in chest x-ray
- Alveolar cells and ductal branches regress

7. MENOPAUSE
• Generalized fatty replacement/atrophy of
epithelium and stroma
• Hormone replacement therapy (HRT)
stimulates residual elements; may increase Ex. of global asymmetry of breast in
mammographic density mammogram

DIVISION OF BREAST

Ex. of asymmetry of breast density in

mammogram
Ex. of asymmetry of dense areas in mammo
because of superimposition or summation
shadow of normal fibroglandular tissues in one
projection
Ex. of asymmetry in mammogram
because of a possible breast lesion
• Result of incomplete regression of the
mammary ridge (milk line) during the
development of the embryo before birth.
• may be found in association with other
conditions
• Usually no treatment is required; however, a
protruding
• Embarrassing supernumerary nipple can be
removed surgically, if desired.
•
Ex. Accessory nipples

Ex. Of accessory nipple in mammo

2. NIPPLE INVERSION
• If congenital / has been present since
birth
-In most cases, it affects both sides.
-It results from tight connective tissue or tissues
with the ductal system connecting to the nipple.
-Often not a medical concern if present at birth
or developed slowly over time, although 4. ACCESSORY BREAST TISSUE
sometimes can interfere with breastfeeding. ■ Defined as “residual (breast) tissue that
• In cases of unilateral inversion that persists from normal embryologic development.”
develops more rapidly (ex. within a few ■ Also known as ectopic breast tissue,
months) - more likely to be a malignancy accessory breast tissue can be found in up to 6%
-Although a number of benign entities have also of the population
been associated with a rapidly developing nipple ■ Responds to hormonal stimulation and may
inversion, including: become more evident during menarche,
1. Mammary duct ectasia pregnancy, or lactation
2. Postsurgical scarring
3. Fat necrosis Ex. Accessory breast tissue
4. Fibrocystic change
5. Mondor disease

Ex. Accessory breast tissue

EX. of retracted/inverted nipple in mammo

Ex. Accessory breast tissue in mammo and

ultrasound

3. ACCESSORY NIPPLES
• Also known as supernumerary nipple, ectopic
nipple, or extra nipple, or polythelia
• A minor malformation of mammary tissue
resulting in extra nipple(s) and/or associated
tissue

The tissue in this patient’s left axilla was a
complete breast with its own separate nipple
that lactated when she nursed.
Ex. Accessory breast tissue in mammo
LESSON 4: CLINICAL BREAST CHANGES
1. BREAST LUMP
• Localized swelling, protuberance, bulge, or
bump in the breast that feels different from
the breast tissue around it or the breast
tissue in the same area of the other breast.
• Common, and most often noncancerous
(benign), particularly in younger women.
Possible causes include:
- an abscess or infection
- adenoma or fibroadenoma
- cysts
- fat necrosis
- lipoma
- breast cancer
Ex. Of palpable lump and diagnosed as cyst in
mammo and ultrasound.
Ex. Of palpable lump and diagnosed as cyst in
mammo
Ex. Of palpable lump and diagnosed as
fibroadenoma in mammo and ultrasound
Ex. Of palpable mass on the breast and diagnosed
as abscess in mammo and ultrasound
The pus/abscess aspirated from the patient’s
breast.
2. SKIN THICKENING
• usually being more than 2 mm in thickness.
• It can result from a number of both benign
and malignant causes which includes:
* For benign:
• infection: mastitis
• conditions causing fluid buildup in the
breast: tends to be bilateral although at
times can be asymmetrical if the patient has
been lying on a particular side prior to the
mammogram (ex. Cardiac failure, renal
failure, and hypoalbuminemia
• trauma to the breast (ex. Mammary fat
necrosis or burns to the skin overlying the
breast with scarring
Breast irradiation: tends to be most
prominent around 6 months after
irradiation
• certain dermatological conditions
For malignant:
• Inflammatory breast cancer: one of the
most concerning causes of skin
thickening: this usually gives diffuse skin
thickening
• Locally invasive breast cancer: tends to
give focal skin thickening
• lymphatic obstruction of metastatic
axillary nodes
• certain metastases to the breast
• Breast lymphoma
Ex. Breast thickening / inflammatory breast
cancer

BREAST WITH NORMAL SKIN THICKNESS
Ex. Diffuse breast thickening in mammogram
Ex. Localized Skin thickening in mammogram
3. DIMPLING
• A possible indication of an inflammatory
breast cancer
• Also known as peau d'orange, causes the
skin to resemble the pitting and uneven skin
of an orange. The skin might also be red and
irritated at times.
• May represent as:
* enlarged, thickened and edematous breast
*tender and painful
*erythematous,
* there may or may not be an underlying
palpable mass
*crusting
*blistering
*retraction of the nipple
*Fixed palpable ipsilateral axillary lymph
nodes, synonymous with metastatic disease,
are frequently observed.
Ex. Skin dimpling
Ex. Skin dimpling in mammogram
4. SKIN IRRITATION
• Chronic itching on your breasts is frequently
accompanied by a rash (as in skin disorders
like eczema or psoriasis).
• Growing breasts that stretch the skin,
allergic reactions, and dry skin can also
cause this.
• Can also be an indication of inflammatory
breast cancer or Paget's disease, but are
uncommon, and also accompanied by a rash,
swelling, redness, or discomfort in the
affected area.
Ex. Skin rash under the breast folds.
Ex. Paget’s disease
EX. Underlying pathology in a female with breast
scaly skin irritation (mammo and ultrasound
images)
5. BREAST PAIN
1. Hormonal fluctuations
- usually happens three to five days before a
period begins and stop aching once it begins.
2. Breast injury
- feeling of sharp, shooting pain after trauma
- tenderness in the breast can last anywhere
from a few days to several weeks.
3. Incorrect bra size and lack of support.
4. Pain that originates in your chest wall, such
as a pulled muscle, inflammation around the
ribs, chest wall trauma, or a bone fracture.
5. Breastfeeding
- An incorrect latch causes painful nipples.
- Tingling sensation during letdown
- Nipple discomfort can be caused by being
bitten, having dry, cracked skin, or
contracting an infection.
6. Breast infection
- ex. Mastitis
7. Medication side effect
- ex. Birth control pills
8. Breast cyst
- sometimes tender and causes discomfort
9. Painful complications from breast implants
- Scar tissue grows too tightly around
implants, causing capsular contracture
- also, possibility of rupture of implants
10. Sometimes sign of breast cancer
- ex. Inflammatory breast CA
6. NIPPLE DISCHARGE (NON-LACTING Ex. SILICONE-INJECTED BREAST IN MAMMO.
BREAST)
- Any fluid that leaks out of the nipple of the
breast.
- POSSIBLE CAUSES ARE:
• papillary lesions of breast: present in ~35-
50% of cases with spontaneous nipple
discharge (Ex. intraductal papilloma)
• fibrocystic change BREAST IMPLANTS
• galactorrhea Classification by Location:
• mammary duct ectasia • Subglandular/ retromammary space -
• ductal carcinoma in situ: 5-21% placed behind the glandular tissue but in
front of the pectoral muscle:
Often, nipple discharge is harmless. Breast • Subpectoral or retropectoral – placed
cancer, on the other hand, is a potential, behind the pectoral muscle
especially if:
- There is presence of lump
- There is only one afflicted breast.
- The discharge is either bloody or colorless.
- The discharge is both spontaneous and
ongoing.
- Only one duct is affected by the discharge. Surgical access
• inframammary (most common)
COSMETIC INTERVENTIONS • periareolar
• transaxillary
1. COSMETIC AUGMENTATION INJECTIONS • transumbilical
- Injection of liquid oil, wax, or gel into breast
parenchyma for cosmetic augmentation. COMMON SITES OF BREAST IMPLANT
- Any type of cosmetic injection may result in a INCISION
foreign body granulomatous reaction:
- Paraffinoma": Reactive mass in surrounding
area(s) of injected paraffin
- "Siliconoma": Reactive mass in surrounding
area(s) of injected silicone oil

GENERAL FEATURES:
• Best diagnostic clue: Numerous bilateral
dense masses ± rim calcifications (Ca++) Augmentation by trans-umbilical approach
• Location (tuba)
o Depends on site and plane of injection
o May be localized (e.g., paraffinoma)
o Widespread, throughout entire breast
(esp. silicone oil)
o May migrate to chest wall, abdominal
wall (esp. silicone)
o May also migrate retromammary
Size: < 1 up to 5 cm nodules or masses
The implants may be composed of saline, silicone
Mammographic findings: or a combination of both and they come in a
• Paraffinoma variety of types including:
- irregular mass(es), droplets, with or • Single-lumen gel:
without fibrotic distortion - silicone gel-filled
• Silicone granulomas • single-lumen adjustable:
- Innumerable round or oval dense masses - silicone gel-filled, to which can be added a
with rim Ca++ variable amount of saline at the time of
- Variable-sized, radiodense, silicone droplets placement
• Silicone oil or PAAG (Polyacrylamide gel) • saline-filled, dextran-filled, PVP-filled:
collections - dextran-filled (some early implants), PVP-
- Large masses of amorphous moderately filled (Bioplasty), and the rest saline-filled
dense intraparenchymal foreign material
• standard double-lumen: Ex. Of capsular contracture shown in
- silicone gel inner lumen, saline outer ultrasound and mri
lumen
• reverse double-lumen:
- saline inner lumen, silicone gel outer
lumen
• reverse-adjustable double-lumen:
- silicone gel inner and outer lumens, • Implant associated hematoma
variable amount of saline added to inner • infection
lumen at the time of placement
• gel-gel double-lumen:
- silicone gel inner and outer lumens
• triple-lumen:
- silicone gel inner and middle lumens,
saline outer lumen
EX. HEMATOMA SURROUNDING BREAST
Possible Complications of Breast Implants: IMPLANT AFTER SURGERY
• Breast implant rupture
• Breast implant collapse: typically occurs
with saline implants and is also sometimes
considered a type of rupture

• Breast implant failure

Ex. Breast implant rupture in mammo.

Ex. Of collapsed implant in mammo

A YEAR BEFORE A YEAR AFTER

• Breast implant herniation

• Breast implant- associated anaplastic large

cell lymphoma (rare)

• Capsular contracture; potential complication

of a breast implant and refers to a tightening
and hardening of the capsule that surrounds
a breast implant. It is a condition that can
distort the shape and cause pain in the
augmented breast. It seems to be the
commonest complication in post-breast
augmentation surgery
MRI OF THE SAME PATIENT
Ex. Of mammo image of scar mimicking a breast
lesion

BREAST REDUCTION
• The plastic surgery method for lowering the
size of big breasts
• Also known as reduction mammaplasty
• Especially for macromastia and
gigantomastia (>1,000 gm overweight per
breast) causes chronic pains in the head,
neck, shoulders, and back, as well as
secondary health issues like poor blood
circulation, impaired breathing, chafing of
the skin of the chest and lower breast
(inframammary intertrigo), brassière-strap
indentations in the shoulders, and the
improper fit of clothes.
Ex. Woman with large breasts before and
after surgery
POST SURGICAL BREAST EXCISION SCAR
• A benign complication of surgical
intervention to the breast tissue. However, it
can be a powerful and potentially perplexing
breast cancer mimicker.
• NOTE: Review of the patient’s past medical
history and imaging will greatly help in the
Radiographic interpretation
Ex. ULTRASOUND IMAGE OF BREAST SCAR
AFTER SURGERY
RADIATION-INDUCED BREAST
ALTERATIONS
• Refers to radiotherapy toxicity over the
breast tissues, whether from targeted breast
cancer treatment or other thoracic
malignancies (ex.lung cancer).
• Features include:
- skin thickening (commonly seen within 6
months of the completion date and slowly
resolve until a certain point where a fibrotic
thickening may persist)
- interstitial edema (diffuse trabecular
thickening representing engorged
lymphatics)
- oil cysts/fat necrosis
- dystrophic calcifications
- focal skin retraction
- glandular atrophy (asymmetry of the
glandular parenchyma noted when
compared to contralateral breast and
decreased breast size)
- breast fibrosis
- radiation-induced breast cancer
Ex. Redness and swelling after irradiation

Ex. Of dystrophic calcifications in mammography

after irradiation
• In mammography:
- Often appears as a spiculated breast lesion,
a weakly marginated soft-tissue mass with
interspersed radiolucent areas. Over time,
the irregularity may fade away. There may
be associated calcifications as well.
LESSON 5: MAMMOGRAPHIC APPEARANCE OF
PATHOLOGY
Breast masses
• Mass - a space occupying 3-DIMENSIONAL
lesion seen in two different projections in
mammography.
If a potential mass is seen in only a single
projection it should be called an 'asymmetry'
until its three-dimensionality is confirmed.
REMEMBER: Ultrasound goes hand-in-hand
with mammography in breast mass evaluation
and shows whether the mass is cystic or solid.
MAMMOGRAPHY FOR EVALUATING MASSES
• NON-PALPABLE MASSES
- falls in asymptomatic women OR for screening
mammography in women 40 years of age or
older
- When screening mammography detects
suspicious findings, such as masses, focal
asymmetries, and architectural distortion,
diagnostic mammography is generally
performed for further evaluation of nonpalpable
mammographic findings
• PALPABLE MASSES
- In women with clinically detected palpable
masses, diagnostic mammography is the initial
imaging modality of choice for evaluating the
palpable breast masses in those 40 years of age
or older,
- For women 30 to 39 years old, either diagnostic
mammography or US may be used for initial
evaluation, but US is the initial imaging modality
in a woman younger than 30 years old.
CHARACTERISTICS OF A MASS IN BREAST
IMAGING
• a ball-shaped object that is approximately the
same size, shape, and density in
mammographic projections.
• whiter than surrounding fibroglandular
tissue
• asymmetric finding compared with the
contralateral breast
• display unique distinguishing characteristics
from normal background tissue.
• are new (if patient has previous breast
imaging)
• MAY have spiculated margins that make
them unique from normal breast tissue.
Radiology units recommend the following
tests to evaluate if one-view observations are
masses or normal tissue:
- Repeating the same mammographic view to see
if the finding persists
- comparing studies with old mammograms,
- performing a 2D diagnostic fine-detail workup
like 2D rolled mammographic views, spot
compression or spot compression magnification
views, and step oblique mammography
- performing Targeted US and tomosynthesis
In all modalities, masses can be described by
the following:
• size
• location of lesion
-laterality, (Ex. left or right)
- quadrant, (Ex. upper/lower inner/outer,
and/or clock face)
- depth, (ex. anterior, middle, or posterior third
- distance from the nipple
• shape, which can be remembered by the
mnemonic ROI:
- round
- oval
- irregular, (ex. neither round nor oval, which is
usually suspicious for malignancy
SHAPE OF MASSES IN BREAST IMAGING
EX. OF OVAL/ROUND SHAPE MASS SEEN IN
MAMMOGRAM AND ULTRASOUND
EX. OF OVAL/ROUND SHAPE MASS SEEN IN
MAMMOGRAM (CYST)

RADIOLOGISTS’ DILEMMA IN 2D
MAMMOGRAMS
• REAL OR FAKE MASS?
• Struggle with findings seen in only one
standard mammographic projection. Their
dilemma is whether the one-view finding is a
fake mass produced by overlapping normal
tissue, called a summation artifact, or if it is
a real mass hidden on the orthogonal view.
EX. OF OVAL/ROUND SHAPE MASS SEEN IN EX. OF BREAST MASS WITH SPICULATED
MAMMOGRAM AND ULTRASOUND (CYST) MARGIN IN MAMMOGRAPHY

Mammogram shows a EX. OF palpable high-

EX. IRREGULAR SHAPE MASS SEEN IN density irregular mass that has partly spiculated
MAMMOGRAM and indistinct margins (arrow) and obscured
borders on its inferior aspect (double arrows),
representing invasive ductal cancer.

EX. IRREGULAR SHAPE MASS SEEN IN

MAMMOGRAM (DUCTAL CARCINOMA)
• Density: (in order of increasing probability
of malignancy of the lesion compared to
equivalent volume fibroglandular tissue)
• fat-containing, which is almost always
benign
• low density
• equal density
• high density
Margins:
circumscribed, obscured, microlobulated,
indistinct, spiculated
NOTE: As the mass margin becomes more
spiculated, the probability of cancer increases.
Masses with well- circumscribed borders are
more likely to be benign

• CIRCUMSCRIBED MARGIN – HAS Sharply

marginated borders THAT indicate no
invasion of the surrounding tissue.
• obscured mass - has a border hidden by
overlapping adjacent fibroglandular tissue,
and that border cannot be assessed
• Microlobulated mass - have small border
undulations, like petals on a flower, and are
more worrisome for cancer than are masses
with circumscribed margins
• indistinct mass - has a margin that can be
seen but is fuzzy. THESE are worrisome for
carcinoma because the fuzzy border suggests
tumor infiltration of surrounding tissue
• spiculated masses - characterized by thin
lines radiating from the central portion of the
mass and are especially worrisome for cancer
 3. Focal asymmetry
- defined as a more fibroglandular-like density in
one breast compared with the other, both in a
corresponding location, is seen on two
orthogonal views, and is less than one quadrant
in size (smaller than the global asymmetry).
- also lacks outward convex borders seen in
masses, and may be interspersed with fat.
-may be dismissed as benign at screening,
whereas others require workup.
- Benign finding if called back from screening
and is worked up, with a 0.5% to 1% probability
of cancer if there are no masses at workup and it
is stable over a 2-to 3-year mammographic
follow-up period
- focal asymmetries that are less than 1 cm are of
concern because they may represent
nonpalpable cancers. It is of particular concern if
the focal asymmetry recalled from screening has
Here a hyperdense mass with an irregular shape
associated architectural distortion or
and a spiculated margin.
calcifications.
Notice the focal skin retraction.

4. Developing asymmetry - a focal asymmetry

that, when compared with older
mammograms, is new, larger, or more
conspicuous than on prior studies.

ASYMMETRIES

CATEGORIES OF ASSYMETRY

1. Asymmetry
- a small area (less than one quadrant of the
breast volume) of fibroglandular-density tissue
seen only on one mammographic projection.
- The asymmetry is either invisible or looks like
normal fibroglandular tissue on the orthogonal
view.
- Most one-view asymmetries represent
overlapping tissues producing a “fake mass” or
summation artifact

2. Global asymmetry
- large, containing one quadrant or more of
fibroglandular-like breast tissue compared with
the same location in the contralateral breast, and
is a real finding because it is displayed on two
orthogonal projections.
- benign if they are not new and have no
associated architectural distortion, palpable
findings, or suspicious calcifications. The
nonpalpable global asymmetry is either an
intrinsic normal variant or is caused by surgical
removal of glandular tissue in the contralateral
breast
- if the finding is new, palpable, or is actually a
mass instead of a global asymmetry, it may
represent cancer and needs workup.
CALCIFICATIONS
• Breast calcifications are deposits of calcium
salts in the breast, which are radio-opaque
on mammography. The majority are benign,
but others can be associated with cancer.
• Bright white specks, like grains of sand, to be
detected against dense white glandular
tissue.

Typically, benign calcifications

• SKIN: lucent centered, usually tightly
grouped, and can be localized
on TANGENTIAL VIEWS if the appearance is
atypical; formed within the
dermis/epidermis
• VASCULAR: parallel tram tracks or
discontinuous linear appearance at the
margins of a tubular structure; formed in
blood vessel walls
• coarse or "popcorn-like": large (>2-3 mm),
sometimes confluent or associated with a
circumscribed mass; formed in
involuting FIBROADENOMAS
• large rod-like: large tubules in a radiating
and sometimes branching distribution
oriented towards the nipple; with the largest
in a breast measuring mean 4 mm long and
0.6 mm wide, usually bilateral, usually
intraductal but sometimes periductal, usually
in older women (>60 years) ; formed
within DUCTAL ECTASIA
• round, including punctate: circular, usually
<1 mm (<0.5 mm if punctate); formed in acini
of TERMINAL DUCTAL LOBULAR UNIT
• rim: "eggshell", lucent centered; formed in
the walls of OIL CYSTS (fat necrosis)
or SIMPLE CYSTS
• dystrophic: irregular, usually >1 mm;
formed after radiation, trauma, or surgery
• milk of calcium: "tea cups" curvilinear or
linear level on the 90° lateral (ML/LM) view
but a smudge on the CC view; formed as
sediment within CYSTS
• suture: linear or tubular calcifications;
formed on loops and knots of surgical sutures

EX. BREAST SKIN CALCIFICATIONS

EX. BREAST VASCULAR CALCIFICATIONS

EX. OF POPCORN CALCIFICATION
EX. ROD-LIKE CALCIFICATION
EX. ROUND AND PUNCTATE CALCIFICATIONS
Distribution
EX. RIM OR “EGGSHELL” CALCIFICATION
EX. Dystrophic calcifications within the
breast are usually seen as
small MACROCALCIFICATIONS with relatively
smooth margins.
EX.” MILK OF CALCIUM” CALCIFICATION IN
MAMMO AND ULTRASOUND
EX. SUTURE CALCIFICATIONS
Suspicious morphology of calcifications
• coarse heterogeneous: irregular,
generally 0.5-1 mm
• amorphous: indistinct and/or small
("powdery", "cloud", or "cottony"), such
that another specific shape cannot be
determined
• fine pleomorphic: variable shape
("shards of glass" or "crushed stone"),
generally <0.5 mm
• fine linear or fine-linear branching:
thin (<0.5 mm), linear, branching or
irregularly arranged ("casting")
• diffuse: scattered randomly throughout
the breast; almost always benign
• regional: scattered in a larger volume (>2
cm in greatest linear dimension) of breast
tissue and not in the expected ductal
distribution; malignancy is less likely but
the overall evaluation also depends on the
morphology
• GROUPED: a cluster of at least 5
calcifications within 1 cm from each
other, in an area at most 2 cm in greatest
linear dimension; more likely to be
malignant with smaller calcific particle
sizes (<1 mm) and suspicious shape
• linear: calcifications arrayed in a line
suggestive of deposition along ducts;
suspicious if there is nO characteristically
benign appearance such as vascular or
large rod-like calcifications)
• segmental: calcium deposits in ducts and
branches of a segment or lobe; suspicious
if not characteristically benign such as
large rod-like