BREAST IMAGING

• Dr Anamika Jha, MD
• Types of breast malignancies
• Modalities:
– USG -Elastography
– Mammography,
– MRI –Dynamic contrast enhanced
– Digital breast Tomosynthesis

• Bi-RADS lexicon
 USG- Indication
1. Palpable mass
2. Discharge
3. Mammographic abnormality
4. To prevent unnecessary biopsies & short interval
follow-up of mammogram of benign lesion
5. To guide intervention
6. To find malignancies missed on mammography
Anatomy
• Modified sweat gland
• 15-20 lobes not well
delineated from each other.
– Parenchyma- lobar duct,
smaller branch ducts, and
lobules
– stromal tissues -compact
interlobular stromal fibrous
tissue, loose periductal and
intralobular stromal fibrous
tissue, and fat
 Terminal ductolobular
• Functional unit of breast
unit(TDLU)
• Consist of lobule & its extralobular
terminal duct
• Lobule- intralobular segment of
terminal duct , ductules & intralobular
stromal fibrous tissue
• Site of origin of most breast pathology
& ANDIs.
• Most breast ca arise in terminal duct
at junction of Intra & extralobular
segment.
• Lobar duct- site for development of
large duct papillomas, duct ectasia-
periductal mastitis complex
• Oriented in taller than wider axis.
Anterior TDLU Posterior TDLU

Long extralobular terminal duct Shorter extralobular terminal duct

More numerous Less numerous

Don’t regress Tend to regress over time

 TDLU

Terminal ductolobular units (TDLUs). The TDLU includes the extralobular terminal duct
and the lobule,
TDLUs present as an isoechoic structure similar to a tennis racket; the head of the racket
(asterisk) represents the lobule, and the handle and neck of the racket (arrows) represent
the extralobular terminal duct.
 Classification malignancies
• Ductal – most common
• Lobular – about
• Stromal
• Metastasis
• Ductal:
– DCIS (basement membrane not invaded): Most
common mammographic feature is
microcalcification.
– Invasive Ductal Carcinoma – most common (75 %)-
not otherwise specified
– Others – Paget’s disease, Tubular, Medullary, Colloid,
Papillary, Inflammatory
• Lobular
– LCIS
– Infiltrating lobular Ca- more often bilateral &
multifocal; 10-15 % of all INVASIVE Ca.
– Phylloides tumor
• Stromal – fibro/ angio/ osteogenic etc

• Metastasis –
– from melanoma/ bronchogenic Ca/ renal Ca.
– Lymphoma –primary/ secondary(more common)
 Lymphatic drainage
• Lymphatic drainage is from deep to superficial toward
subdermal lymphatic network, then to periareolar
plexus(Sappey’s plexus) & finally to axilla.
• Internal mammary lymph nodes.
• Most drainage of breast is to axillary lymph nodes.
• Rotter nodes lie between pectoralis major & minor
muscle
 Indication for Mammography
1. Diagnostic: including masses, skin thickening,
deformity, nipple retraction, nipple discharge
and nipple eczema
2. Breast cancer screening – DCIS
3. Follow-up of patients with previously treated
breast cancer
4. Guidance for biopsy or localization of lesions not
visible on ultrasound
 Standard mammographic views
• Standard : Mediolateral oblique and craniocaudal views.
• Additional views-
– Exaggerated Craniocaudal (XCCL) View- lateral tissue (axillary tail of Spence).

– Lateral Views: Mediolateral (ML) and Lateromedial (LM)

true lateral projection. For needle localization.

– Axillary Tail View (Cleopatra View)- axillary tail of the breast. Similar to
mediolateral view but allows evaluation of breast tissue more laterally
oriented
– Cleavage Valley view.
– Tangential View
• Spot Compression Views- For evaluation of
margins and morphology of lesions. Spreads
structures; useful to determine if densities are
real or not.

• Magnification Views- Provides additional

information on margins, satellite lesions, and
microcalcifications. Can also be useful for
asymmetrical tissue or architectural distortion.
• Breast compression contributes to image quality by:-

 immobilizing the breast –reducing motion unsharpness.

 producing a more uniform thinner tissue
 Lower scattered radiation
 More even penetration of x-rays.
 Less magnification
 Less geometric blurring,
 Less superposition of tissues
COMPOSITION
a- The breast are almost entirely fatty.
Mammography is highly sensitive in this
setting.
b- There are scattered areas of
fibroglandular density.
The term density describes the degree of
x-ray attenuation of breast tissue but not
discrete mammographic findings.
c- The breasts are heterogeneously dense,
which may obscure small masses.
Some areas in the breasts are sufficiently
dense to obscure small masses.
d - The breasts are extremely dense,
which lowers the sensitivity of
mammography.
 Mass
• A 'Mass' is a space occupying 3D lesion seen in
two different projections.

• If a potential mass is seen in only a single

projection it should be called a 'asymmetry'
until its three-dimensionality is confirmed.
Shape
MARGIN
-Circumscribed: Usually a benign
finding.
-Obscured or partially obscured, when
the margin is hidden by superimposed
fibroglandular tissue.

-Microlobulated. suspicious finding.

-Indistinct (historically ill-defined).

a suspicious finding.
-Spiculated with radiating lines from
the mass is a very suspicious finding
Circumscribed malignant Benign lesions with
SOLs spiculated margins
• Medullary • Radial scar
• Mucinous & intracystic • Postoperative scar
(papillary) carcinoma • Fat necrosis
• Metastases • Haematoma
• Lymphoma • Abscess
• Sarcoma • Granulomatous mastitis
Density
•Relative to the expected attenuation
of an equal volume of fibroglandular
breast tissue.

•Most breast cancers - equal or higher

density than an equal volume of
fibroglandular tissue.

•Breast cancers are never fat-

containing (radiolucent) although they
may trap fat
 Fat Containing
• fat -oil cyst, lipoma,
galactocele
• mixed lesions -
hamartoma or
fibroadenolipoma.
• A fat containing mass will
overwhelmingly Mediolateral oblique view of large, oval,
represent a benign mass. circumscribed, FAT-CONTAINING mass (large
arrows) with soft tissue densities within (small
arrows) -Hamartoma
Asymmetries

• Unilateral deposits
of fibroglandular
tissue not
conforming to the
definition of a mass.
• Seen in one
projection- Caused
by superimposition
of normal breast
tissue.
Focal asymmetry : real finding rather
than superposition.
This has to be differentiated from a
mass.
Global asymmetry: consisting of an
asymmetry over at least one quarter
of the breast and is usually a normal
variant.
Developing asymmetry: new, larger
and more conspicuous than on a
previous examination.

Here an example of a focal asymmetry seen on MLO and

CC-view.
Local compression views and ultrasound did not show
any mass.
 Asymmetry vs Mass
Asymmetry Mass

• concave outward borders • convex outward borders

• usually is interspersed with • appears denser in the

fat center than at the
periphery.
• An example of global
asymmetry.
Not a normal variant -
associated features, that
indicate the possibility of
malignancy like skin
thickening, thickened septa
and subtle nipple retraction.
• PET-CT shows diffuse
infiltrating carcinoma.
 Architectural distortion
• Normal architecture is distorted with no definite
mass visible.

• Thin straight lines or spiculations radiating from a

point, and focal retraction, distortion or straightening
at the edges of the parenchyma.

• Mass that causes architectural distortion, the

likelihood of malignancy is greater than in the case of
a mass without distortion.
the distortion of the normal breast architecture on oblique view (yellow circle)
and magnification view.
A resection was performed and only scar tissue was found in the specimen
 CALCIFICATION

Calcifications of intermediate concern

and of high probability of malignancy –
biopsy

Within this last group the chances of

malignancy are different depending on
their morphology (BI-RADS 4B or 4C)
and also depending on their
distribution.
Typically benign
 Skin
• These are usually lucent-centered and often
pathognomonic in their appearance.

• Unusual forms may be confirmed as skin

deposits by performing mammographic views
tangential to the overlying skin.
 Tattoo sign

at the oblique and craniocaudal view, the calcifications look exactly the same in
configuration.
This is called the tattoo sign .
Spot views subsequently proved that these were dermal calcifications.

Vascular
Parallel tracks, or linear calcifications that are
clearly associated with tubular structures.
Coarse or “popcorn-like”
These are the classic large (>2-3 mm in
diameter) calcifications produced by an
involuting fibroadenoma.
 Large rod-like
• Associated with ductal
ectasia/ plasma cell mastitis
• May form solid or
discontinuous smooth
linear rods
• Usually ≥ 1 mm in diameter.
• Generally solid when
secretions calcify in the
lumen of ectatic ducts.
Rim
Deposited on the
surface of a sphere
like oil cysts, fat
necrosis or form
calcified debris in the
ducts.
Dystrophic
Usually form in the
irradiated breast or in
the breast following
trauma.
Irregular in shape
Coarse and usually
larger than 0.5 mm in
size.
Often have lucent
centers.
Milk of calcium
Sedimented calcifications in
macro or microcysts.
Semilunar, crescent shaped,
curvilinear (concave up) or
linear defining the dependent
portion of cysts.
Most important feature of these
calcifications is the apparent
change in shape of the calcific
particles on different
mammographic projections
Suspicious morphology
Amorphous/
indistinct
Small or hazy in
appearance

Diffuse scattered- benign.

Clustered, regional, linear

or segmental distribution
may warrant biopsy.
BI-RADS 4B
Coarse
Heterogeneous
irregular, conspicuous
calcifications

Generally larger than 0.5 mm

Associated with malignancy but

can be present in areas of
fibrosis, fibroadenomas or
trauma representing evolving
dystrophic calcifications.

BI-RADS 4B
 Fine
pleomorphic

vary in sizes and shapes

usually smaller than 0.5

mm in diameter.

BI-RADS 4C
Fine Linear or Fine-
Linear Branching
Thin, linear or curvilinear
irregular calcifications.

May be discontinuous

Smaller than 0.5 mm in width.

Their appearance suggests filling

of the lumen of a duct involved
irregularly by breast cancer

BI-RADS 4C
DISTRIBUTION
• Diffuse: random distribution
• Regional: breast tissue > 2 cm
greatest dimension
• Grouped (historically
cluster): lower limit 5
calcifications within 1 cm and
upper limit a larger number of
calcifications within 2 cm.
• Linear: arranged in a line,
which suggests deposits in a duct.
• Segmental: suggests deposits in a
duct or ducts and their branches.
Skin thickening
focal or diffuse
and larger than 2
mm.
 Category 2: Benign
A benign finding in the mammography report, like:
• Follow up after breast conservative surgery
• Involuting, calcified fibroadenomas
• Multiple large, rod-like calcifications
• Intramammary lymph nodes
• Vascular calcifications
• Implants
• Architectural distortion clearly related to prior surgery.
• Fat-containing lesions such as oil cysts, lipomas, galactoceles and
mixed-density hamartomas.
 Category 3: Probably Benign
• less than a 2% risk of malignancy.
• It is not expected to change over the follow-up interval

Lesions appropriately placed in this category include:

• Nonpalpable, circumscribed mass on a baseline mammogram
(unless it can be shown to be a cyst, an intramammary lymph
node, or another benign finding),
• Focal asymmetry which becomes less dense on spot
compression view
• Solitary group of punctate calcifications
• The initial short-term follow-up of a BI-RADS 3 lesion is a
unilateral mammogram at 6 months, then a bilateral follow-up
examination at 12 months.

• If the findings shows no change in the follow up the final

assessment is changed to BI-RADS 2 (benign) and no further
follow up is needed.

• If a BI-RADS 3 lesion shows any change during follow up, it will

change into a BI-RADS 4 or 5 and biopsy should be performed.
 Category 4: Suspicious
• do not have the classic appearance of malignancy but are
sufficiently suspicious to justify a recommendation for biopsy.

• BI-RADS 4 has a wide range of probability of malignancy (2 -

95%).

• Subdivisions Category 4 into 4A, 4B and 4C , relevant

probabilities for malignancy be indicated within this category
so the patient and her physician can make an informed
decision on the ultimate course of action.
DO

• Use for findings sufficiently suspicious to justify biopsy

• Use in the presence of suspicious unilateral lymphadenopathy without abnormalities in the breast

• Do use Category 4a in findings as:

- Partially circumscribed mass, suggestive of (atypical) fibroadenoma
- Palpable, solitary, complex cystic and solid cyst
- Probable abscess

• Do use Category 4b in findings as:

- Group amorphous or fine pleomorphic calcifications
- Nondescript solid mass with indistinct margins

• Do use Category 4c in findings as:

- New group of fine linear calcifications
- New indistinct, irregular solitary mass
 Category 5: Highly Suggestive of
Malignancy
• BI-RADS 5 must be reserved for findings that
are classic breast cancers, with a >95%
likelihood of malignancy.

• Percutaneous tissue diagnosis is

nonmalignant, this automatically should be
considered as discordant.
DO

• Use if a combination of highly suspicious findings are present:

– Spiculated, irregular mass + high-density.
– Fine linear calcifications + segmental or linear arrangement .
– Irregular spiculated mass + associated pleomorphic calcifications.

• Use in findings sufficiently suspicious to justify Category 5 and the patient or referring
clinician refrain from biopsy because of contraindications or other concerns.
Then add sentence: "Biopsy should be performed in the absence of clinical
contraindications".

DON'T
• Don't use if only one highly suspicious finding is present.
Then use Category 4c.
 Category 6: Known Biopsy-Proven
Malignancy
DO
• Use after incomplete excision
• Use after monitoring response to neoadjuvant chemotherapy

DON'T
• Don't use after attempted surgical excision with positive margins and no
imaging findings other than postsurgical scarring. Then use category 2 and
add sentence stating the absence of mammographic correlate for the
pathology.

• Don't use for imaging findings, demonstrating suspicious findings other

than the known cancer, then use Category 4 or 5.
Digital breast tomosynthesis (DBT)
• Full Field Digital Mammography- sensitive but high number of false
negatives largely due to the presence of dense tissue that may
affect lesions conspicuity. [Mammogram= “summation image”].
• Breast tomosynthesis is a new tool that can be expected to
ameliorate this problem by reducing or eliminating tissue overlap.
• Breast tomosynthesis technology is essentially a modification of a
digital mammography unit to enable the acquisition of a three-
dimensional (3D) volume of thin-section data.
• Images are reconstructed in conventional orientations by using
reconstruction algorithms similar to those used in computed
tomography (CT).
 Comparision of suspicious
mammographic & sonographic findings
Suspicious mammographic findings Suspicious sonographic findings

spiculation Spiculation (thick echogenic halo)

Irregular or poorly defined margin Angular margins

Microlobulation Microlobulation

Calcifications Calcification

Linear calcification pattern Duct extension

Branching calcification pattern Branch pattern

Mass or nodule Taller than wide*

Assymetric density Acoustic shadowing*

Developing density Hypoechogenicity*

 Comparision of morphologic & histologic features
Morphologic features Histologic features
of suspicious sonographic findings: DCIS or
Surface characteristics Hard findings
Invasive.
spiculations Spiculations & thick echogenic halo
Angular margins Angular margin
lobulation Acoustic shadowing
Shapes Mixed findings
Taller than wide Hypoechogenicity
Duct extension Taller than wide

Branch pattern Microlobulation

Internal characteristics Soft findings

Calcifications Duct extension

Acoustic shadowing Branch pattern
Hypoechogenicity Microcalcification
• Orientation: unique to US-imaging, and
defined as parallel (benign) or not parallel
(suspicious finding) to the skin.
Spiculation. A, Spiculation is a “hard” mammographic finding that indicates invasion. B,
Coarse spiculations (between arrows) present as alternating hypoechoic and hyperechoic lines
radiating from the nodule on ultrasound. The hypoechoic parts represent fingers of invasive
tumor or ductal carcinoma in situ, and the hyperechoic lines represent the interface between
the tumor and surrounding tissue.
 Shape Taller than wide
• Larger in the AP dimension than in any horizontal dimension are
suspicious for malignancy.
• Primary feature of small solid malignant nodules of volume 1cc or
less
• As lesion enlarge, they become more wider than tall
• About 70% of malignant nodules with maximum diameters less
than 10 mm are taller than wide. Only 20% of malignant nodules
over 2.0 cm in maximum diameter are taller than wide.
Duct extension & branch pattern (Soft)

• Duct extension manifest as single

projection of solid growth toward
nipple from main nodule.
• Branch pattern manifest as projection
of solid nodule into multiple small
ducts peripherally.
Duct extension of ductal carcinoma in situ. DCIS growing within the lobar duct toward
nipple. Most invasive duct carcinomas contain DCIS components. In some cases the DCIS
growing away from the tumor toward the nipple within the lobar duct may grossly
distend the duct enough to allow recognition of duct extension sonographically
(arrows).
 Acoustic shadowing
• Suggests presence of invasive malignancy
• Due to desmoplastic component &
spiculation of tumour

• D/D of malignant lesion showing acoustic

shadowing
– Low grade to intermediate invasive ductal
carcinoma,
– Invasive lobular carcinoma,
– Tubulolobular carcinoma,
– Tubular carcinoma
 Acoustic enhancement
• D/D of malignant lesion showing enhanced
sound transmission-
– High grade invasive ductal carcinoma,
– high nuclear grade DCIS,
– colloid ca,
– medullary ca,
– invasive papillary ca
 Benign findings
• Only if no suspicious finding are present, one of three
benign findings should be sought.
1. Pure and marked hyperechogenicity
2. Elliptical shape with wider than taller orientation with
lesion completely encompassed by a thin ,echogenic
capsule.
3. Gently lobulated shape with wider than taller
orientation with 3 or fewer lobulation, with complete
thin echogenic capsule
 Complicated & complex cyst
Complex cyst – thick irregular walls, mural
nodules, thick septations & internal blood flow.
• Increased risk of containing papillomas &
carcinomas.

Complicated cyst – echogenic fluid, fluid debris

level, or fat-fluid level.
• Most non simple cyst fall within benign
FCC spectrum & malignant cysts are
relatively uncommon.
USG in Implants
• To identify type of implant,
implantation site, intra or
extracapsular rupture , silcon
granuloma, herniation, capsule
infection
Breast implant rupture. A, Classic findings of intracapsular rupture of a single-lumen silicone
gel implant are the “stepladder sign” (arrows) and hyperechoic silicone gel (asterisk) in the
right breast. Several linear, horizontally oriented echoes represent folds in a collapsed shell.
Several of these are double echogenic lines that represent the inner and outer surfaces of
each fold of the shell (arrows). The extravasated gel that lies outside the implant shell has
become hyperechoic (asterisk). Note that only a single echogenic line that represents the peri-
implant capsule can be seen on the right (arrowhead).
Regional lymph node assessment
1. Size
• minimum diam. > 1cm considered abnormal.
• Poor criteria for metastasis
2. Shape
• Metastatic lymph node is abnormally round-late
finding
• Eccentric cortical thickening is much more
sensitive than roundening
• Abnormally hypoechoic cortex.
Hallmark of metastasis- cortical thickening
 Lymph nodes: spectrum of normal appearance
A, In young patients the mediastinum of the lymph node tends to be uniformly hyperechoic
because the medullary cords and sinuses fill the entire mediastinum (m).
B, In older patients who have had repeated episodes of inflammation, the center of the
mediastinum (m) becomes infiltrated with isoechoic fat, and the medulla (arrowhead)
becomes compressed into a thin band just deep to the hypoechoic cortex (c).
 spectrum of cortical thickening.
A, Metastases that implant near the midcortical sinusoids tend to thicken the cortex
focally and equally in inward and outward directions.
B, Metastases that implant within the subcapsular sinusoids tend to cause focal,
outwardly bulging cortical thickening (“mouse ear”).
C, Metastases that implant toward the inner part of the cortical sinusoids cause focal
cortical thickenings that bulge inwardly into the lymph node mediastinum (“rat bite”
defect).
• In case of uniform cortical thickening,
- In inflammation all LNs show
uniform cortical thickening, however
in metastasis, adjacent LN is normal.
Advances in USG imaging of Breast
• Sonoelastography
• 3D USG
• Contrast Enhanced US
 Sonoelastography
• Noninvasive imaging technique that can be used to
depict relative tissue stiffness or displacement (strain)
in response to an imparted force.
• Stiff tissues deform less and exhibit less strain than
compliant tissues in response to the same applied
force.
• Equivalent to palpation!
 Tissue compression(force)
Tissue strain (displacement)

Soft tissue Hard tissue

(Benign) ( malignant)

More displacement Less displacement

Elasticity image reconstruction according to strain(displacement) distribution

Elasticity image
 Interpretation:
• Score 1: Even strain for entire lesion: Benign lesions

• Score 2: mosaic strain: mostly benign lesion/ DCIS

• Score 3: strain only in peripheral: benign(intraductal papillma)

>> malignant.

• Score 4: no strain in entire lesion: characteristics of

malignancy

• Score 5: no strain even in surronding : infiltrating malignant

lesion.
 3D Ultrasound
• Enables reconstruction of image in coronal plane
which is otherwise not obtainable by 2D imaging.
• Automated Breast Volume scanning is a
technique which acquires volume data of the
whole breast and permits MPR of the image in
coronal and sagittal planes
• 3D USG to guide biopsy
Contrast-enhanced ultrasonography
• The finding that Doppler signals may be difficult to
detect either because of small vessel size or
inadequate equipment has led to the development of
ultrasound contrast agents.
• They are encapsulated microbubbles, which increase
the acoustic scattering from the tissues through which
they.
• Contrast enhancement improves detection of small
vessels with slow and low-volume blood flow. It
reduces equipment dependence and could
theoretically improve standardization by also
providing dynamic flow information which can be
quantified.
MRI
MASS
Always have mammogram in hand
KINETIC ANALYSIS
Type 1: slow rise and a continued rise with time.
A lesion with a type 1 curve has a chance of 6% of being
malignant.
Type 3: rapid initial rise, f/b a drop-off with time (washout) in
the delayed phase. A lesion with this type of curve is
malignant in 29-77%.
Type 2: a slow/rapid initial rise f/ b a plateau in the delayed phase, which is allowed a variance of 10% up or
down. The chance being malignant lies somewhere between the 6% of the type 1 curve and the 29-77% of the
type 3 curve.
Many physicians will biopsy lesions with type 2 curves.
• For non-mass enhancement, kinetics are not
very useful.
• If there is clumped enhancement in a breast it
must be biopsied, even though there are no
areas with a type 3 curve.
 CAD- Computer Aided Detection
• Purely kinetic evaluation.
• It does not evaluate the anatomy or pathology of the
images.
CAD looks at the curves and peak enhancements for the
contrast (automated kinetics).
• Extra features, motion registration during subtraction,
which can correct for a patient's movement during the
exam.
• In CAD, red is bad: it means type 3 washout, and probably
cancer.
The CAD shows a large area of red superimposed on
the breast lesion
T1 and T2
T1 High
Central high signal on a T1-weighted
image can be seen in intramammary
lymph nodes or fat necrosis.
Fat is also seen in hamartomas.

HAMARTOMA
 • Moderate and low signal on T2-fatsat
The T2 fat-suppressed sequences are for
T2
detecting lesions with high signal, not
High signal on T2-fatsat
water! Lesions that are bright on T2
moderate or low signal.
include cysts, lymph nodes and fat Moderate and low signal intensities can be
necrosis. caused by cancer.
These are all benign lesions.

EXCEPT- colloid carcinoma.

It is the exception to the rule that all
things with bright signal on T2 fat-
suppressed images are benign.
Non-mass enhancement
 Linear non mass enhancement-
Focal non mass enhancement- DCIS stromal fibrosis
•
Nuclear medicine
Molecular Breast Imaging is under investigation as an adjunct to
mammography. Presented clinical indications for the most commonly used
agent Tc 99m sestamibi scintimammography include examining
premenopausal dense breasts, palpable lesions with low-suspicion
mammographic finding and evaluation of response to neoadjuvant
chemotherapy for locally advanced breast cancer (Khalkhali & Vargas
2001).
• The drawbacks reported are false-positives due to high uptake found in
some fibroadenomas, inflammatory processes, and post-surgical changes.