Mammographic Appearance of Breast Cancer

By:
Dr. Dorria Salem
Professor of Radiology
Cairo University
-------------------------------------------------------------------------------------------------------
BI-RADS
Breast Imaging Reporting And Data System
• Mammographic findings should be reported according to the Breast Imaging
Reporting & Data system (BI-RADS), established by the American college of
Radiology (ACR) :
-----------------------------------------------------------------------------------------------
Benign Lesions
1-Well defined

2-Regular outline

3- +/- Surrounding halo

4- +/- Macrocalcification
----------------------------------------------------------------------------------------
Commonest Benign Lesions
• Fibroadenoma
• Cyst
• Lipoma
-----------------------------------------------------------------------------------------------
1)Fibroadenoma
• U/S: Ovoid= longer than deep.
• Sharply defined margins.
• Fairly uniform internal echoes.
-------------------------------------------------------------------------------------------------------
2)Cyst
Mammogram:
• Rounded or ovoid, well defined.
• Surrounding halo.
• May show Egg shell calcification
Follow up :
1- disappear (resobed) 2-decrease in size.
3-increase in size
U/S: rounded or oval sharply defined margins.
• No internal echoes.
• Bright posterior acoustic enhancement

----------------------------------------------------------------------------------------------------

1)Lipoma
• U/S: hypoechoic similar in echotexture to subcutaneous fat but distinguished
from it by the capsule.
-----------------------------------------------------------------------------------------------------
A
Sure Signs of malignancy
1-Mass: spiculated

2- Microcalcification:
clustered
pleomorphic

B
Suspiciously Malignant Lesions
1- Mass a-illdefined margin
b- microlobulated c-increasing density

2-Architectural distortion

3-calcification a-micro/clusterd
b- changing

C
Findings may be associated with Ca
1-Assymmetry a-tissue density
b- ducts
c- veins

2-skin& trabecular thickening

3-Nipple retraction, deviation,inversion

4-Axillary LN enlarged
-------------------------------------------------------------------------------------------------------
A) Sure Malignant Lesions
1) Malignant mass
• Dense mass with a spiculated margin
• Irregular mass with a spiculated margin
DD a) Postsurgical scar
• Looks different between the ML and CC projections while Ca looks the
same on both
b) Fat necrosis
This pt had a biopsy with benign results 4yrs earlier. This spiculated mass with
skin retraction proved to be fat necrosis.
c) Radial scar
Benign scarring process characterized by dramatic spiculation. It is
idiopathic, unrelated to known trauma or surgery Excisional biopsy

---------------------------------------------------------------------------------------------
2)Microcalcification
• A- Clusterd Microcalcification
Def: 5 or more calcification each </= 0.5mm in a 1cc volume of breast tissue
B- Pleomorphic
Def: Different in shape eg fine, linear,branching +irregular
2) Malignant Microcalcifications
A) Clusters
B) Pleomorphic:
1-Fine
2-Linear
3-Irregular
4-Branching
---------------------------------------------------------------------------------------------
• B) Suspicious Findings
• 1) Lesions with illdefined margins
Illdefinition:
Common yet nonspecific characteristic that suggests a malignant process
2) Lesion with microlobulated margins
• Fibroadenoma may have a lobulated outline
• The more lobulated the lesion, the more likely it is to be malignant
i.e. when the lobulations are multiple and measure only several mm, the degree
of suspicion should increase
3) Architectural distortion
• Ca does not always produce a mammographically visible mass.

• It frequently disrupt the natural tissue architectural distortion

• This distortion of architecture may be the only visible evidence of the

malignant process
DD:
• Post surgical Scarring
• Fat necrosis
• Radial Scar
4) Distorted Parenchymal edge
• In the normal breast, the parenchymal cone interface is scalloped by Cooper’s
Ligament attaching by the retinacula cutis to the skin.
• Ca developing at the edge distort this relationship and cause flattening,
retraction or bulging of the parenchyma in this region.

5) Density Increasing over time

• The breast is an “involuting organ”
• Involution results in fat deposition
• i.e. Breast becomes more radiolucent over time
• Focal areas with in densities warrant careful ex

6) Clustered microcalcification
• Def: 5 or more calcification each </= 0.5mm in a 1cc volume of breast tissue
• DD: Benign secretory calcification= Plasma cell mastitis → continuous thick
rods that do not branch, frequently bilateral
7) Changing Calcification
• As with masses, new microcalcification not present on previous mammogram
are of particular concern

-------------------------------------------------------------------------------------------------------
C) Findings that may be associated with Breast Cancer

1) Assymetric tissue density

• Asymmetric breast tissue differs from a focal asymmetric density
• Focal asymmetry in the density of the tissues in one part of a breast relative to
its mirror image on the other side should be followed up.
• The asymmetry is of greater significance when there is a corresponding
palpable abnormality on physical examination.
2) Asymmetric ducts /
3)Asymmetric veins
• Considered normal variants unless associated with a palpable abnormality or
other signs of Ca
4) Skin + Trabecular thickening

due to:

a) Direct invasion by Tu → Tethering Cooper’s ligament

Or
b) Obstruction of the lymphatic or venous return
5) Nipple retraction, Deviation or Inversion
• As a 2ry sign of malignancy, nipple retraction is generally associated with
large Ca .
• Other benign and congenital causes should be first excluded.
6) Enlarged Axillary LN
• Causes:
1- Benign hyperplasia
2-Lymphoma
3-Metastatic
4-2ry breast malignancy
----------------------------------------------------------------------------------------------------
Take home Message…
 Review clinical data and use US to help assess a palpable or
mammographically detected mass.

Be strict about positioning and adequate technical aspects.

 Requirements to optimize image quality.


Be alert to subtle features of breast cancers.

Compare current images with multiple prior studies to look for subtle increase
in lesion size or density.

Look for other lesions when one abnormality is seen.

Judge a lesion by its most malignant features.

 Double Reading.
  Advanced Technology
Advances in Technology
• WHAT IS IT ?
• IS IT LUXURY ?
-----------------------------------------------------------------------------------
• 1-Digital Mammography
• 2- MR-Mammography
---------------------------------------------------------------------------------------
There are 7 good reasons to go now for digital…
1. Superior in cancer detection.
2. Reduction in ex. time, retakes and recalls.
3. Improved Image quality and lesion detectability.
4. Perfect analysis of microcalcification.
5. High diagnostic accuracy.
6. Dose reduction.
7. Improve workflow with centricity solutions HIS / RIS
--------------------------------------------------------------------------------------------
When to ask for MR-M?

1)Pre operative staging:

To give additional pre operative information about:
1- Tu size
2- extensive intraductal component:
3-Multifocality= 2 or more Ca within one breast quadrant
Incidence 25%-50%
4- Multicentricity= 1 or more Ca present in another quadrant than the one harbouring
1ry Ca with a minimum distance of 2 cm
Incidence 15%-30%
5- synchronous bilateral breast Ca
----------------------------------------------------------------------------------------
When to ask for MR-M?

----------------------------------------------------------------------------------------------------
When to ask for MR-M?
3) Metastases of unknown 1ry MR-M is indicated when mammo + US fail to identify
intramammary 1ry
4) Follow up after lumpectomy
when mammo & US fail to solve the problem
5) Differentiation between Scar & Ca
6) Follow up after lumpectomy
when mammo & US fail to solve the problem
7) Follow up after breast reconstruction with implant
MR-M should be performed at regular intervals
8) Prosthetic complications
Intracapsular rupture ( 80-90% )
-----------------------------------------------------------------------------------------------
2- MR M
• Indications :
• 1-Pre-operative a) Multicentricity
• b) Bilaterality
• c) Size / extent assessment
• d) Multifocality
• 2-Treatment Response
• 3-Metastases of unknown 1ry
• 4-Post-operative FU a) Post lumpectomy
• b) Post implant
-----------------------------------------------------------------------------------------
DON’T FORGET
• Suspicious Lesion → Biopsy
• The sure diagnosis always lie on the tip of the biopsy needle.
• The safety and low morbidity of breast biopsy makes it difficult to be
postponed when a significant doubt exists.
• Make advantage of the advances in Technology
---------------------------------------------------------------------------------------------