Clinical Breast Imaging: A Patient Focused Teaching File, 1st Edition

Chapter 1 - My Aunt Minnie

 

Terms

·     Amorphous calcifications

·     Artifacts

·     Calcified parasites

·     Cysts

·     Dystrophic calcifications

·     Extracapsular implant rupture

·     Fibroadenolipomas

·     Gel bleed

·     Hair

·     Hickman catheter

·     Hyalinizing fibroadenomas

·     Implants

·     Intracapsular implant rupture

·     Keloids

·     Lipomas

·     Lucent centered calcifications

·     Lymph nodes

·     Milk of calcium

·     Negative density artifacts

·     Nipple rings

·     Oil cysts

·     Plus density artifacts

·     Radiolucent mass

·     Rod-like calcifications

·     Seborrheic keratoses

·     Skin folds

·     Sternalis muscle

·     Vascular calcifications

·     Wire fragments

·     Wire localization

Introduction

The term “Aunt Minnie” is used in radiology to characterize lesions that have a distinctive, unique appearance. Most radiology residents learn about Aunt Minnie early in their careers. While planning this book, I thought a chapter on Aunt Minnie would be easy to put together. I have discovered that this is not so! At least in mammography, the concept of Aunt Minnie is difficult to apply and I have struggled in selecting what should be included in this chapter. Does Aunt Minnie really always look the same? If for the same entity there is some variation in appearance, can it still be Aunt Minnie? Is your Aunt Minnie the same as my Aunt Minnie?

By this point you are probably wondering why I am dwelling on this. Probably this is by way of a disclaimer! I have elected to illustrate entities I define as Aunt Minnie. Some of you may not recognize my Aunt Minnie; however, the entities presented are distinctive and should be recognized as benign or iatrogenic. Rarely do these require additional evaluation, short-interval follow-up, or intervention.

For Patient Discussions

In approaching “patient” (as opposed to “case”) discussions, consider the 4 D's. The first is detection. Is there a potential abnormality? The second is a description of a confirmed finding based on complete information (e.g., additional clinical and imaging evaluations). Your description should lead you and the listener to a differential and the likely diagnosis you will propose. The third D is your differential. When considering the possibilities, remember that all findings have benign and malignant considerations and you should move through the list in a logical manner. Try not to jump back and forth from benign to malignant. Tell the listener what you think the lesion could be, not what it is not. Also, try to be specific; saying that “this is likely a malignancy or cancer” is not very insightful. The last D is what you think the diagnosis is most likely to be.

 

Patient 1

Figure 1.1. Screening study, 42-year-old woman: craniocaudal (A) and mediolateral oblique (B) views. (C) Craniocaudal view. Skin lesions projecting beyond the skin (thin arrows) are easily identified. Skin lesions superimposed on the parenchyma (thick arrows) can often be identified by a sharply defined lucency (air) partially or completely outlining their margins.

 

 

What is your diagnosis?

If you are not sure, what can you do to be 100% sure?

Multiple masses are projecting on the breast parenchyma bilaterally. On close inspection, air is seen as a thin radiolucency, partially or completely outlining the margins of several of the masses (Fig. 1.1C, thicker arrows). Those in tangent to the x-ray beam are seen extending beyond the breast (Fig. 1.1C, thin arrows). Bilateral skin lesions may be seen in otherwise healthy women or, when this numerous, in women with neurofibromatosis. These patients can be challenging. We are often mesmerized by benign findings and neg lect more subtle findings that potentially reflect breast cancer. So, do not let benign, obviously malignant, or clinical findings distract you from reviewing the mammogram completely. You need to be even more focused in looking for potential signs of early breast cancer around and in between obvious findings. If there is any question about a mass being on the skin you can examine the patient and, if still not sure, place a metallic BB on the identified skin lesion and obtain follow-up images with the BB (and skin lesion) in tangent to the x-ray beam.

BI-RADS® category 1: negative. BI-RADS® category 2: benign finding is used if the skin lesions are described in the body of the report. Next screening mammography is recommended in 1 year.

 

Patient 2

Figure 1.2. A: Skin lesion, right breast, photographically coned view. The interstices of the lesion are sharply outlined by air. A portion of the mass is seen extending beyond the breast. B: Skin lesion, left breast, photographically coned view. Metallic BB placed on the skin lesion. A thin, sharply defined lucency (air) outlines the margins of the mass as well as some of the interstices of the lesion. Craniocaudal (C) and photographically coned (D) views of skin lesion, laterally in the right breast. Metallic BB placed on skin lesion. The margins and interstices of the lesion are sharply defined by a surrounding lucency (air).

 

What is the diagnosis in these three patients, and how can you be certain?

What else could you do?

Seborrheic keratoses: Characteristic mammographic appearance is demonstrated with these three patients. When superimposed on the breast parenchyma, skin lesions are often partially, or completely, outlined by a thin radiolucency (air), as are the interstices of the verrucous lesions. When they are in tangent to the x-ray beam, their extension beyond the skin is outlined by air (radiolucent). Although metallic BBs are often used to mark these skin lesions, the mammographic appearance of the verrucous lesions is distinctive. Metallic BBs are more helpful on smooth skin lesions, because these are more likely to simulate a breast lesion when superimposed on the breast parenchyma on the two standard views of the breast (e.g., craniocaudal and mediolateral oblique views). When a technologist uses a BB, she indicates the reason on the woman's history form and affixes a sticker on the films (e.g., “BB on mole” or “BB on lump”) indicating the reason for the use of the BB. Unless the skin lesions are too numerous to mark, the routine use of BBs to mark skin lesions can avert some callbacks.

Seborrheic keratoses are common benign epidermal tumors distributed on skin that bears hair. They do not develop on mucosal surfaces and are infrequent under the age of 30 years. They are common, typically multiple, and continue to develop as patients age. A familial predilection with a possible autosomal dominant form of inheritance has been described. Seborrheic keratoses are typically flat when they first develop and over time can become more verrucous, polypoid, and pedunculated in appearance. Rarely, rapid proliferation or increases in the size of pre-existing lesions may be an indication of an internal malignancy (Leser-Trélat sign).

Patient 3

Figure 1.3. A: Mediolateral oblique, photographically coned view of an oval, mixed-density (fat containing) mass. B: Ultrasound image, antiradial (ARAD) projection of a hypoechoic mass with a focus of central echogenicity corresponding to the mass shown in (A) at the 2 o'clock position, 10 cm from the left nipple. C: Mediolateral oblique, photographically coned view of a round mass with what may be an eccentric fatty hilum. D: Ultrasound image, antiradial (ARAD) projection of palpable (PALP) hypoechoic mass (arrows), with an eccentric focus of echogenicity corresponding to the mass shown in (C) at the 2 o'clock position, 4 cm from the left nipple. E: Ultrasound image, left axilla, demonstrating an oval lymph node (arrows) characterized by a thin hypoechoic cortex and central area of echogenicity corresponding to the fatty hilum seen on mammograms. F: Ultrasound image, left axilla, demonstrating an oval mass (arrows) with a thin hypoechoic cortex and a central oval area of echogenicity. Ultrasound images, in radial (RAD) (G) and antiradial (ARAD) (H)projections, of an oval mass (arrows) characterized by a hypoechoic cortex and a central focus of echogenicity, at the 10 o'clock position, 10 cm from the right nipple. I: T1-weighted sagittal image, precontrast, demonstrating a mass with a central focus of lower signal intensity. J: T1-weighted sagittal image, immediately postcontrast, at the same tabletop position shown in (I), demonstrates rapid enhancement of the cortical rim of the mass.

What are imaging findings of intramammary lymph nodes?

The mammographic appearance of lymph nodes is variable (Fig. 1.3A, C). Most commonly, intramammary lymph nodes are well circumscribed, oval (reniform), mixed-density (fat containing) masses localized to the upper outer quadrants. However, they can be found anywhere, including the inner quadrants, and may fluctuate in size and density. They may have a prominent fatty component relative to the water-density portion or vice versa. Rarely, lymph nodes disappear, only to reappear on subsequent mammograms. The mammographic appearance of “normal” lymph nodes is usually distinctive enough that no additional imaging is indicated.

Ultrasound is used adjunctively in patients in whom a lymph node is suspected but a fatty hilum is not definitely seen mammographically. Ultrasound is also the primary imaging modality used in patients who are under the age of 30 years, pregnant, or lactating, who present with a palpable finding. On ultrasound, lymph nodes are typically well-circumscribed masses with a hypoechoic cortical area and a hyperechoic central, or eccentric focus, corresponding to the fatty hilar region seen mammographically (Fig. 1.3B, D, E, F, G, H). If power Doppler is used, blood flow is seen associated with the hyperechoic region.

On T2-weighted magnetic resonance images, lymph nodes demonstrate high signal intensity. Following contrast administration, lymph nodes are characterized by rapid contrast uptake on T1-weighted images. This uptake is followed by either a plateau or rapid washout. Contrast enhancement may appear rimlike when the hilar region is centrally located (Fig. 1.3I, J). Vessels can sometimes be seen in the hilar region.

Mammographically, if a lymph node increases in size and density and there is associated loss of the fatty hilum with indistinct or spiculated margins, biopsy may be indicated; in many women, however, these changes are reactive and do not reflect a malignant process. Similarly, on ultrasound, biopsy is considered if there is thickening and bulging of the cortical area, often asymmetric and microlobulated, with concomitant thinning and apparent mass effect, or complete loss, of the hyperechoic hilar region. Increased blood flow can be seen in some of these lymph nodes.

 

 

Patient 4

Figure 1.4. Screening study. Craniocaudal (A) and mediolateral oblique (B) views. Diagnostic study in a different patient presenting with a “lump” in the right breast. Craniocaudal (C) and mediolateral oblique (D) views (metallic BB marking palpable finding). Craniocaudal (E) and mediolateral oblique (F)spot compression views of the palpable finding in the right breast.

 

How would you describe the findings?

What is your diagnosis?

Mixed-density (fat containing) masses are imaged mammographically in these two patients consistent with fibroadenolipomas (also called hamartoma, breast-within-a-breast). Fatty, glandular and fibrous tissues are surrounded, and separated, from the remainder of the breast tissue by a fibrous pseudocapsule. As illustrated by these two patients, the proportions of each tissue type vary from patient to patient. In some women the lesions are mostly fatty, in others glandular tissue predominates. They can be detected on screening studies (Fig. 1.4A, B, left breast) or, in some patients can present as a palpable finding (Fig. 1.4C, D, right breast). Rarely, they occur in accessory axillary glandular tissue and may enlarge rapidly.

On ultrasound, fibroadenolipomas are usually separable from surrounding normal tissue and characterized by an admixture of hypo- and hyperechoic areas with disruption of normal tissue architecture. The posterior acoustic features of these lesions are variable and include no posterior acoustic features, enhancement, shadowing, or a combined pattern (areas of enhancement and areas of shadowing).

Variable combinations of adipose tissue, fibrous stroma, and lobular structures are seen histologically and, although separable from the adjacent breast tissue, hamartomas lack a true capsule. Rarely, myxoid and chondroid hamartomas are reported histologically when the lesions contain muscle and cartilage, respectively. A myxoid hamartoma has been reported in a 36-year-old male presenting with a slowly growing breast mass. Breast cancer can arise in fibroadenolipomas, so the tissue in these lesions should be evaluated for the development of any mass, distortion, or calcifications as thoroughly as breast tissue anywhere else.

BI-RADS® category 2: benign finding. Next screening mammogram is recommended in 1 year.

 

Patient 5

Figure 1.5. Screening study. Craniocaudal (A) view exaggerated laterally and mediolateral oblique (B) view, photographically coned. Screening study, different patient. Craniocaudal (C) and mediolateral oblique (D) views, photographically coned. Ultrasound images in radial (E) and antiradial (ARAD) (F)projections of a palpable mass at the 6 o'clock position, 2 cm from the left nipple, radiolucent on the mammogram (not shown).

 

How would you describe the findings?

What is your diagnosis?

Radiolucent, well-circumscribed masses (small arrows) with a thin fibrous capsule consistent with lipomas; these rarely calcify. Unlike oil cysts, which have a variable sonographic appearance but often simulate cysts, lipomas are well circumscribed, solid, slightly hypo- or isoechoic masses on ultrasound (large arrows). In some women, lipomas can be slightly hyperechoic and a small amount of posterior acoustic enhancement may be noted (Fig. 1.5E, F). A gentle mass effect on surrounding tissue and Cooper ligaments can also be seen with some lipomas. Rarely, lipomas can be seen within the pectoral muscle.

BI-RADS® category 2: benign finding. Next screening mammography is recommended in 1 year.

Patient 6

Figure 1.6. A Diagnostic study in a 60-year-old patient presenting with a “lump” in her right breast. Spot tangential (A) view of the “lump” with a metallic BB placed at the site of concern. The patient has had a reduction mammoplasty. Ultrasound images, radial (RAD) (B) and antiradial (ARAD) (C)projections of palpable finding, right breast.

 

How would you describe the findings?

What is your diagnosis?

Two adjacent 5-mm round, well-circumscribed radiolucent masses are seen mammographically, corresponding to the “lump” described by the patient. Given the history of a reduction mammoplasty, these are consistent with oil cysts. The diagnosis is established mammographically. Radiolucent masses in the breast are benign. The benign nature of the palpable finding is discussed with the patient, and she is reassured that this is not breast cancer and that it will not become cancerous. A definitive report is issued to avoid unnecessary surgery.

BI-RADS® category 2: benign finding. Next screening mammography is recommended in 1 year.

On physical examination, there is a discrete, hard, lobulated mass palpated at the 12 o'clock position, 1 cm from the right nipple. A macrolobulated, nearly anechoic mass with significant shadowing is imaged, corresponding to the palpable finding. Although the ultrasound is included for illustrative purposes, the diagnosis is made on the mammographic findings (i.e., ultrasound is not indicated when a radiolucent mass is seen mammographically). Oil cysts can have a variable appearance on ultrasound, ranging from simulating a simple cyst to a complex cystic mass or a mass with significant shadowing as seen here.

Patient 7

Figure 1.7. Screening study, 49-year-old woman. Craniocaudal (A) view. Mediolateral oblique view. Craniocaudal (C) and mediolateral oblique (D) views, photographically coned, left breast. Screening study, 46-year-old woman. Photographically coned images (E, F) of same area in the right breast, 2 years apart.

 

 

How would you describe the findings?

These are oil cysts with eggshell or rim calcification. Oil cysts commonly develop following trauma or surgery; however, most patients do not recall the trauma (and may not recall surgery). These are round or oval, well-circumscribed, radiolucent masses. As illustrated here, thin calcifications can develop in the wall of the cyst. With time these may stabilize or decrease progressively in size (Fig. 1.7E, F) and, in some patients, eventually resolve completely.

Steatocystoma multiplex is a rare, autosomal dominant condition characterized by the presence of multiple cutaneous cysts appearing during adolescence and increasing progressively with age involving the anterior trunk, back, proximal extremities, and external genitalia. Multiple oil cysts are seen mammographically.

BI-RADS® category 1: negative. BI-RADS® category 2: benign finding is used if the findings are described in the body of the report. Next screening mammogram is recommended in 1 year.

 

Patient 8

Figure 1.8. Screening study, 63-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast. Mediolateral oblique (C) view, left breast, photographically coned. Screening study, 40-year-old woman. Craniocaudal (D) views. Craniocaudal (E) views, 1 year following (D). Craniocaudal (F) view, left breast, photographically coned. Craniocaudal (G) view, left breast, photographically coned, 1 year following (F).

 

 

How would you describe the findings?

What procedure have both of these patients undergone?

A radiolucent mass with mural and internal curvilinear calcifications is seen in the left breast in Fig. 1.8A–C. The appearance of some of the internal calcifications suggests the presence of smaller lucent masses within the dominant mass. Also noted is asymmetric tissue inferiorly on the right mediolateral oblique view demonstrating a swirling pattern (Fig. 1.8B). The left breast is smaller than the right. The findings suggest a history of reduction mammoplasty, which is confirmed on the patient's history sheet.

In the second patient, multiple mixed-density masses of varying sizes are present bilaterally (Fig. 1.8D). A few dense calcifications are associated with some of the masses (Fig. 1.8D, F). A year later, many more coarse calcifications are noted associated with the mixed-density (fat containing) masses (Fig. 1.8E). The calcifications are now more curvilinear in appearance, seemingly outlining a cluster of lucent masses (Fig. 1.8G). As the calcifications have increased, the overall size and associated soft tissue component of some of the masses has decreased. The presence of multiple, bilateral oil cysts may reflect a history of trauma or, as in this patient, reduction mammoplasty. Comparison films, if available, will be helpful in establishing a change in overall breast size following the surgery, as well as the development of the oil cysts.

What are the imaging findings associated with fat necrosis?

In the acute setting, fat necrosis following reduction mammoplasty may present with one or multiple, mixed-density masses; some may be spiculated. As the inflammatory process associated with fat necrosis resolves, single or multiple, uni- or bilateral oil cysts of varying sizes may remain. Although some may develop rim calcifications, most develop coarser, curvilinear calcifications, as demonstrated in these two patients. With time, these may stabilize, continue to calcify, or some eventually resolve completely. In some patients, these become palpable as they calcify 1 or 2 years following the surgery. When they are palpable, it is important to reassure the patient that the palpable finding is benign and requires no further intervention. It is also important that a definitive report be issued.

BI-RADS® category 1: negative. BI-RADS® category 2: benign finding is used if the findings are described in the body of the report. Next screening mammogram is recommended in 1 year.

 

Patient 9

Figure 1.9. Screening study, 70-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast.

What is the diagnosis and what BI-RADS® category would you assign?

Multiple, well-circumscribed, dense masses, some with macrolobulations and varying amounts of associated dense, coarse calcifications, are present in the left breast. These are hyalinizing fibroadenomas with associated dystrophic calcifications (i.e., popcorn-type calcifications). As estrogen levels decrease, the epithelial component in fibroadenomas atrophies and is replaced by dense, hyalinized fibrous tissue. These changes may be characterized mammographically by a decrease in size, an increase in density, and the development of dense, dystrophic calcifications in a pre-existing well-circumscribed mass. Because these calcifications develop in hyalinized fibrous tissue, they are variable in size, shape, and density (i.e., there is no preformed space molding the developing calcifications). Also noted is a well-circumscribed, mixed-density oval mass superimposed on the pectoral muscle on the mediolateral oblique view, consistent with a lymph node.

BI-RADS® category 2: benign finding. Next screening mammogram is recommended in 1 year.

 

Patient 10

Figure 1.10. Screening study, 65-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast, photographically coned. Craniocaudal (C) view, left breast. Macrolobulated masses with dense, coarse calcifications represent hyalinizing fibroadenomas. Although no soft tissue component is present, a cluster of dense tightly packed calcifications (arrow) also represents a hyalinizing fibroadenoma. Arterial calcification (arrowheads) is present.

 

What observations can you make, and do you think this woman needs to be called back for additional evaluation?

Two macrolobulated, dense masses with partially well circumscribed margins and coarse, dense calcifications are imaged in the left breast. A cluster of dense, tightly packed calcifications is also present (Fig. 1.10C, arrow), with no associated soft tissue component. Scattered benign calcifications and arterial calcification Fig. 1.10C arrowheads) are incidentally noted. These are all hyalinizing fibroadenomas. It is important to recognize that a mass is not always seen in association with the dystrophic calcifications of a fibroadenoma (i.e., a cluster of calcifications alone can represent a hyalinizing fibroadenoma). These findings require no additional evaluation or short-interval follow-up. However, don't be lulled by obviously benign findings; make sure to focus your attention on the remainder of the mammogram.

 

Patient 11

Figure 1.11. Screening studies, 43-year-old woman. Mediolateral oblique (A) view left breast, photographically coned. Mediolateral oblique (B) view, left breast, 1 year after (A), photographically coned. Mediolateral oblique (C) view, left breast, 3 years after (A), photographically coned. Mediolateral oblique (D) view, left breast, 5 years after (A), photographically coned.

What is your diagnosis?

An oval mass, with partially obscured and well-circumscribed margins and associated dense coarse calcifications, is imaged anterior to the pectoral muscle. On subsequent screening studies, the mass decreases slightly in size, becomes denser, and the calcifications increase in number, size, and density. These findings are diagnostic of a hyalinizing fibroadenoma with dystrophic calcifications (i.e., developing popcorn calcification). This finding is benign and requires no additional evaluation or short-interval follow-up.

 

Patient 12

Figure 1.12. Diagnostic study, 48-year-old patient presenting with a “lump” in the left breast. Mediolateral oblique (A) views with metallic BB on the “lump” described by the patient in the left breast. Spot compression (B) view of palpable finding. Left subareolar area (C), 5 years before (A, B), photographically coned view. Ultrasound images, radial (RAD) (D) and antiradial (ARAD). (E) projections of palpable (PALP) finding. Ultrasound images, radial (RAD) (F) and antiradial (ARAD) (G) projections of palpable (PALP) finding in the left breast at the 11:30 o'clock position, 2 cm from the nipple. A round, hypoechoic mass with heterogeneous echotexture, dense calcifications (arrows), and shadowing are imaged, corresponding to the palpable area of concern to the patient. Shadowing (arrowheads) is intermittently seen associated with some of the calcifications.

 

How would you describe the mammographic and ultrasound findings, and what is your recommendation for this patient?

Lymph nodes are present in both axillary regions. A 2-cm mass with obscured margins and associated coarse calcifications is seen in the left subareolar area on the mediolateral oblique views. On the spot compression view, the margins are irregular and indistinct. Compared with the study from 5 years previously, the mass is now more dense and the calcifications are larger.

On physical examination, a readily mobile, hard, nontender mass is palpated at the 11:30 o'clock position, 2 cm from the left nipple. On ultrasound, a round mass with heterogeneous echotexture and shadowing is imaged corresponding to the palpable finding. Several areas of hyperechogenicity (Fig. 1.12F, G, arrows), some curvilinear, others with associated shadowing (Fig. 1.12F, G, arrowheads), are noted consistent with the calcifications seen mammographically. The mammographic findings are diagnostic of a hyalinizing fibroadenoma with associated dystrophic calcifications. Although an ultrasound is shown here for completeness, the diagnosis is made on the mammographic findings. This is explained to the patient; she is reassured that what she feels is a benign lesion that will not turn into cancer and has been present for 5 years with no significant changes. A definitive report is issued describing the palpable finding as a hyalinizing fibroadenoma requiring no further intervention or short-interval follow-up.

As the estrogen levels decrease, the epithelial elements in fibroadenomas atrophy and are replaced by an increasing amount of fibrous tissue. Mammographically, hyalinizing fibroadenomas may decrease slightly in size and become more dense so that, in some women, they become more readily apparent while some undergo calcification, as demonstrated in this patient.

BI-RADS® category 2: benign finding. Next screening mammogram is recommended in 1 year.

 

 

Patient 13

Figure 1.13. Screening mammogram, 63-year-old woman. Craniocaudal (A) view, left breast. Craniocaudal (B) view, left breast, 3 years previously.

How would you describe the findings?

Linear, parallel, tram-track-like calcifications represent vascular (arterial) calcifications. This patient has developed dense vascular calcifications in the span of 3 years, suggesting the possibility of diabetes or atherosclerotic disease that may be significant. In this patient, I describe the development of vascular calcifications in the mammographic report. It is reasonable to contact the referring physician directly, particularly if the patient provides no information relative to underlying diabetic, cardiac, or renal disease (e.g., what medications is the patient taking?), to discuss the findings.

Reportedly, arterial calcifications are more common in postmenopausal women who are not on hormone replacement therapy (HRT). The rapid development of arterial calcifications in some perimenopausal women might serve as an indication for considering HRT; also, mammography may prove helpful in monitoring the effectiveness of HRT. The prevalence of arterial calcifications increases with age among all women. However, it is important to recognize that arterial calcifications are reportedly four times more likely in diabetic patients (i.e., those on insulin or oral hypoglycemic agents) and three times more likely in hypertensive patients (i.e., those on oral antihypertensives) compared to women with no history of diabetes or hypertension.

Arterial calcifications in young women, particularly when in conjunction with skin thickening (specifically axillary skin) and breast microcalcifications, have also been reported in women with pseudoxanthoma elasticum (PXE). This is an autosomal recessive disorder characterized by fragmentation, clumping, and calcification of elastic fibers in skin, eyes, and arteries. Yellowish skin papules and redundant skin folds at flexural sites (e.g., axilla, groin) are common cutaneous findings. Angioid streaks in the retina affect almost 100% of patients after the age of 30 years and can result in loss of visual acuity. Peripheral vascular disease, resulting from calcification of medium-sized arteries, can lead to claudication, hypertension, angina, myocardial infarction, cerebrovascular accidents, bowel angina with resulting gastrointestinal bleeding, and complicated pregnancies, often resulting in miscarriages. Although skin changes commonly develop during childhood, the disorder is not usually diagnosed until the third or fourth decade, when systemic complications become apparent.

BI-RADS® category 2: benign finding. Next screening mammogram is recommended in 1 year.

 

Patient 14

Figure 1.14. Screening mammogram, 55-year-old woman. Mediolateral oblique (A) view, right breast. Mediolateral oblique (B) view, right breast, 4 years previously.

How would you describe the findings?

Dense, linear, parallel, tram-track-like calcifications represent vascular (arterial) calcification. In this patient, the arterial calcification is resolving. Typically, vascular calcifications develop and can be seen mammographically as women age. As illustrated by this patient, if the underlying cause(s) of atherosclerosis is (are) treated successfully, vascular calcifications can resolve partially or completely, but this is the rare case.

Reportedly, arterial calcifications are more common in postmenopausal women who are not on hormone replacement therapy (HRT). The rapid development of arterial calcifications in some perimenopausal women might serve as an indication for considering HRT; also, mammography may prove helpful in monitoring the effectiveness of HRT. The prevalence of arterial calcifications increases with age among all women. However, it is important to recognize that arterial calcifications are reportedly four times more likely in diabetic patients (i.e., those on insulin or oral hypoglycemic agents) and three times more likely in hypertensive patients (i.e., those on oral antihypertensives) compared to women with no history of diabetes or hypertension.

Arterial calcifications in young women, particularly when in conjunction with skin thickening (specifically axillary skin) and breast microcalcifications, have also been reported in women with pseudoxanthoma elasticum (PXE). This is an autosomal recessive disorder characterized by fragmentation, clumping and calcification of elastic fibers in skin, eyes, and arteries. Yellowish skin papules and redundant skin folds at flexural sites (e.g., axilla, groin) are common cutaneous findings. Angioid streaks in the retina affect almost 100% of patients after the age of 30 years and can result in loss of visual acuity. Peripheral vascular disease, resulting from calcification of medium-sized arteries, can lead to claudication, hypertension, angina, myocardial infarction, cerebrovascular accidents, bowel angina with resulting gastrointestinal bleeding, and complicated pregnancies, often resulting in miscarriages. Although skin changes commonly develop during childhood, the disorder is not usually diagnosed until the third or fourth decade, when systemic complications become apparent.

BI-RADS® category 2: benign finding. Next screening mammogram is recommended in 1 year.

 

Patient 15

Figure 1.15. Screening study, 80-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) views, screening study 5 years prior to (A, B). Screening study, 76-year-old woman. Craniocaudal (D) view, right breast. Craniocaudal (E) view, right breast, 2 years prior to (D).

 

 

How would you describe the findings, and what would you recommend next?

Large rodlike calcifications are present bilaterally (Fig. 1.15A, B). These calcifications are typically coarse, dense, and rod shaped. As demonstrated, they develop progressively (compare Fig. 1.15A with Fig. 1.15C), are often oriented toward the nipple, and the process is commonly bilaterally. Branching may be seen, and when the calcifications develop periductally, a central lucency may be noted. These calcifications have been described as being associated with duct ectasia; a variety of terms have been used to describe the process, including periductal mastitis, secretory disease, comedo mastitis, plasma cell mastitis, and mastitis obliterans. Also noted is the progressive development of arterial calcifications.

Progressive development of large rodlike calcifications is noted in the right craniocaudal views shown in Fig. 1.15D. These are benign and require no additional evaluation or intervention. Also noted is vascular calcification. Annual screening mammography is recommended for these two patients. However, a word of caution is indicated when large rodlike calcifications develop focally in a patient, particularly if the calcifications are not oriented toward the nipple and there are no other calcifications in either breast. Rarely, ductal carcinoma in situ (DCIS) with central necrosis can present with calcifications that may be mistaken for the type of calcification illustrated here.

BI-RADS® category 1: negative. BI-RADS® category 2: benign finding is used if the calcifications are described in the body of the report. Next screening mammogram is recommended in 1 year.

 

Patient 16

Figure 1.16. Screening study, 42-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Digital screening study, 40 year-old woman. Craniocaudal (C) and mediolateral oblique (D) views of the left breast, photographically coned. Ultrasound image (E) in the radial (RAD) projection at the 2 o'clock position, 1 cm from the left nipple. Screening study, 72-yearold woman. Craniocaudal (G) and mediolateral oblique (H) views, photographically coned. Ultrasound Image (I) at the 10 o'clock position, 2 cm from the left nipple. Ultrasound image (F) in the radial (RAD) projection at the 2 o'clock position, 1 cm from the left nipple. One of several subcentimeter cysts in the upper outer quadrant of the left breast. Echogenic foci (arrows) and a linear focus of echogenicity (arrowheads) are noted in the dependent portion of the cyst. This is milk of calcium. (J) Ultrasound image (J) at the 10 o'clock position, 2 cm from the left nipple. A cyst with calcifications (arrows) and a curvilinear focus of echogenicity consistent with calcium out of suspension in the dependent portion of the cyst (arrowheads).

 

 

For each mammogram shown, describe the findings

What is the diagnosis in all three patients, and is a biopsy or short-interval follow-up indicated for any of these patients?

Amorphous calcifications of varying size and shapes are diffusely scattered throughout the dense parenchyma on the craniocaudal views (Fig. 1.16A). On the mediolateral oblique views, the calcifications are well defined, higher in density compared to the craniocaudal view, and most demonstrate a curvilinear or linear appearance (Fig. 1.16B).

A cluster of amorphous calcifications is seen laterally in the left breast on the craniocaudal view (Fig. 1.16C). The individual calcifications are better defined, denser, and demonstrate a more linear appearance on the mediolateral oblique view (Fig. 1.16D). On ultrasound (Fig. 1.16E), a cluster of subcentimeter cysts is imaged at the 2 o'clock position, 1 cm from the nipple (only one of which is shown), corresponding to the area of the clustered calcifications seen mammographically. Discrete echogenic foci (Fig 1.16F, arrows) and a linear area of echogenicity (Fig 1.16F, arrowheads) are noted in the dependent portion of the cyst, corresponding to some of the layering calcifications identified mammographically (Fig. 1.16F).

A cluster of round and oval calcifications is imaged in the right craniocaudal view (Fig. 1.16G). The calcifications shift in position and their overall distribution suggests that they are contained within a nonvisualized round mass on the mediolateral oblique view (Fig. 1.16H). On ultrasound (Fig. 1.16I), a cyst is imaged at the 10 o'clock position of the right breast, 2 cm from the nipple, the expected location of the calcifications seen mammographically. Discrete echogenic foci (Fig 1.16J, arrows) and an irregular curvilinear focus of echogenicity (Fig 1.16J, arrowheads) are imaged in the cyst, reflecting the calcifications seen mammographically (Fig. 1.16J). As expected, the calcifications are contained in a cyst.

These three patients demonstrate the variable appearance of milk of calcium. The diagnosis is established on the mammographic features of the calcifications. This reflects calcium in suspension within microcysts, less commonly in macrocysts. Amorphous calcifications are seen on the craniocaudal view. On mediolateral oblique and 90-degree lateral views, the calcium layers creating sharply defined, curvilinear calcifications (“teacups”). The characteristic mammographic feature of this type of calcification, therefore, is a differential appearance between craniocaudal and 90-degree lateral views, although it can also be seen on mediolateral oblique views in many patients. If the diagnosis is in question on the screening study, the patient is called back to confirm the diagnosis with a 90-degree lateral view. This process can be diffuse and bilateral, unilateral or focal. Although it is most common for the calcium to be in suspension, in some patients there are individual calcifications (often with somewhat geometric shapes) in suspension that can be seen changing appearances between craniocaudal and mediolateral oblique or 90-degree lateral views. If an ultrasound is done, cystic changes, some with associated calcifications, are often identifiable.

BI-RADS® category 1: negative. BI-RADS® category 2: benign finding is used if the calcifications are described in the body of the report. Next screening mammogram is recommended in 1 year.

 

Patient 17

Figure 1.17. Screening study, 67-year-old patient. Craniocaudal (A) view, right breast. Craniocaudal (B) view, right breast, 2 years after (A). Craniocaudal (C) view, right breast, 4 years after (A).

 

How would you describe the findings, and what is your diagnosis?

This patient illustrates the progressive development of dystrophic calcifications. These calcifications develop in stromal fibrous tissue and not in predefined anatomic spaces or structures (e.g., acini, ducts, or vasculature). Consequently, they are variable in size, shape, and density. When diffuse and bilateral, they can reflect the presence of an underlying metabolic (e.g., renal failure, hyperparathyroidism), inflammatory, or degenerative process. When focal, they can be associated with hyalinizing fibroadenomas, sclerosed papillomas, or fat necrosis (posttrauma, postsurgical). In most women, no etiology is identified.

BI-RADS® category 1: negative. BI-RADS® category 2: benign finding, is used if the calcifications are described in the body of the report. Next screening mammogram is recommended in 1 year.

 

Patient 18

Figure 1.18. Screening study, 72-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, photographically coned.

What is the most likely diagnosis?

A focus of coarse, dystrophic calcifications is noted in this patient's mammogram. Although no mass is seen, these most likely reflect a hyalinized fibroadenoma. The bottom line is that these are benign and require no additional evaluation, short-interval follow-up, or intervention.

BI-RADS® category 1: negative. BI-RADS® category 2: benign finding is used if the calcifications are described in the body of the report. Next screening mammogram is recommended in 1 year.

 

Patient 19

Figure 1.19. Screening study, 53-year-old woman. Craniocaudal views, photographically coned.

How would you describe the findings, and do you think additional evaluation is indicated?

Clusters of round and oval, lucent-centered calcifications are imaged in the posteromedial aspect of the breasts. These are skin calcifications in a common location and require no additional evaluation. Regardless of size, lucent-centered calcifications are benign.

BI-RADS® category 1: negative. Next screening mammogram is recommended in 1 year.

 

Patient 20

Figure 1.20. Screening study, 54-year-old woman. Mediolateral oblique views, photographically coned.

What is your impression?

Silicone implants are present in a subglandular location. A triangular density is imaged, extending superiorly from the right implant along the anterior edge of the pectoral muscle. This is consistent with silicone and an extracapsular implant rupture. Extravasated silicone is noted as a high-density material that can assume a variety of shapes and sizes. In some women, silicone is seen as round high-density masses or triangular globs in the breast, whereas in others it is within the lymphatic system extending into the axilla.

What is gel bleed?

Relative to silicone implants, consider three different concepts: gel bleed, intracapsular implant rupture, and extracapsular implant rupture. Gel bleed is a natural phenomenon associated with silicone implants. The implant shell, made of silicone, is a semipermeable membrane that allows for the egress or bleed of silicone naturally. This bleed may be low or high grade, depending on the amount of cross-linking of the silicone elastomere shell. Gel bleed is not imaged on mammograms or ultrasound. On magnetic resonance images, gel bleed is characterized by the filling of wrinkles (“keyhole”) present in otherwise intact implants. This is in contrast with the extravasation of silicone resulting from a disruption of the implant shell.

What types of implant ruptures are there, and how are they diagnosed?

After an implant is placed in the body, a fibrous capsule forms around the implant. If rupture of the implant shell occurs and there is an intact “native” fibrous capsule, the extravasated silicone is contained by the capsule (i.e., intracapsular implant rupture). This type of implant rupture is not apparent on a mammogram; it may be identified on ultrasound and it is easily diagnosed with magnetic resonance imaging (MRI). If the patient's own capsule is disrupted, rupture of the implant can result in extracapsular extension of the extravasated silicone. This type of rupture can be diagnosed mammographically, on ultrasound, and with MRI.

 

Patient 21

Figure 1.21. Screening study, 40-year-old woman. Craniocaudal (A) views, photographically coned. Craniocaudal (B) view, right breast medially, photographic cone down. Implant displaced views (C), craniocaudal projection.

 

What is your diagnosis?

Round, high-density globules of silicone are imaged at the edge of the silicone implant, medially on the right. These are better imaged on the implant-displaced view (Fig. 1.21C). This finding is consistent with extracapsular implant rupture.

 

Patient 22

Figure 1.22. Screening study, 75-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast.

What is your impression?

Saline implants are present in a subglandular location. The significant folding of the implant on the oblique view and the relative lack of opacity in the craniocaudal view is consistent with partial (nearly complete) collapse of a saline implant.

 

Patient 23

Figure 1.23. Diagnostic study, 57-year-old patient presenting with a “lump” in the upper outer quadrant of the right breast. Craniocaudal (A) views, photographically coned laterally. Craniocaudal (B) view, right breast, photographically coned medially. Ultrasound image (C), radial (RAD) projection at the site of the palpable (PALP) finding, 10 o'clock position, 12 cm from the right nipple. Ultrasound image (D), antiradial (ARAD) projection at the site of the palpable (PALP) finding, 10 o'clock position, 12 cm from the right nipple. Craniocaudal (E) views, photographically coned laterally. Extravasated silicone is present (arrows) closely apposed to the right implant posterolaterally. Craniocaudal (F) view, right breast, photographically coned medially. Extravasated silicone is present (arrows) closely apposed to the right implant medially. Also noted is calcification of the capsule (arrowheads). Ultrasound image (G), radial (RAD) projection at the site of the palpable (PALP) finding, 10 o'clock position, 12 cm from the right nipple. The appearance of silicone on ultrasound is variable. In this image, extravasated silicone is imaged as a cluster of round and irregular hypoechoic masses.

 

How would you describe the imaging findings, and what is your diagnosis?

High-density globules adjacent to the right implant (arrows, Fig. 1.23E, F) are diagnostic of an extracapsular implant rupture. On ultrasound, round and irregular hypoechoic masses (arrows, Fig. 1.23G), some with angular margins and an echogenic halo, are imaged at the site of the palpable abnormality, 10 o'clock position, right breast, 12 cm from the nipple. The “snowstorm” appearance of extravasated silicone is also demonstrated in some of the images obtained during the ultrasound study (Fig. 1.23D); an irregular curvilinear echogenic focus is imaged, characterized by shadowing associated with high specular echoes.

 

 

Patient 24

Figure 1.24. A: Craniocaudal views, photographically coned view medially. B: Craniocaudal views, photographically coned view medially.

 

What is the pertinent observation?

Swirls of hair are seen on one (Fig. 1.24A, right) and both (Fig. 1.24B) craniocaudal views posteromedially. As the patient is positioned for the craniocaudal view she is asked to turn her head away from the breast being imaged. As this is done, hair can come down along the neck and project on the breast. Because the hair is a distance from the cassette, the swirls are not sharp (geometric unsharpness). Although hair may be superimposed on any image and in any posterior location, it is most commonly seen posteromedially on craniocaudal views. The technologist needs to make sure that all the patient's hair is pulled back. Repeat views may be indicated if a potential lesion could be obscured. In the examples presented, the right craniocaudal (Fig. 1.24A) needs to be repeated because the density of the superimposed hair may obscure a cluster of calcifications or a small spiculated mass.

Patient 25

Figure 1.25. Right (A) and left (B) craniocaudal views, photographically coned anteriorly.

How would you describe the findings?

What is your working hypothesis, and how can it be tested?

High-density material with linear (wavy) and punctate forms involving the anterior aspect of the breasts represents an artifact. This is zinc oxide ointment (Desitin) on the skin. If there is any question that this may represent calcifications, the patient is asked if she applied something to her skin; she can be examined and asked to wipe her breast clean before follow-up films are taken to confirm partial or complete removal of the artifact. Note the presence of bilateral arterial calcification.

 

Patient 26

Figure 1.26. A: Craniocaudal views, photographically coned medially. B: Different patient. Mediolateral oblique view, photographically coned superiorly.

What is demonstrated in these two patients?

A high-density, tubular structure is imaged posteromedially in the left breast (Fig. 1.26A). Similarly, a tubular structure with dense edges is seen superimposed on the left pectoral muscle in a different patient (Fig. 1.26B). These are retained Dacron cuffs from Hickman central venous catheters. These are typically found in the upper inner quadrants of either the right or left breast. Although rare, abscess formation around the cuff has been reported and should be suspected if an irregular mass that may contain air is seen associated with the cuff.

 

Patient 27

Figure 1.27. Screening study, 62-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast, photographically coned. Craniocaudal (C) and mediolateral oblique (D) views, 1 year after (A) and (B), photographically coned.

 

What is your impression?

What recommendation would you make based on the most recent set of images?

A retained wire fragment is imaged in the upper inner quadrant of the left breast, consistent with the history provided by the patient of a breast biopsy preceded by wire localization “many” years ago (Fig. 1.27A, B). The wire fragment is stable in appearance and position compared with several prior mammograms, and the patient is asymptomatic. On her next screening mammogram (Fig. 1.27C, D), the wire is fragmented and the larger of the two fragments has migrated such that it may be embedded in the pectoral muscle; however, this cannot be confirmed because the wire could not be imaged in its entirety on the craniocaudal view. Given the changes noted in the wire, excisional biopsy following preoperative wire localization of the fragments is recommended. A specimen radiograph obtained following the surgical procedure documents excision of the wire fragments, as well as the wire used for the current localization procedure.

Specimen radiography is indicated following all preoperative wire localizations for several reasons, including documentation that the localized lesion and localization wire have been excised. The radiograph is also used to mark the location of the lesion of interest for the pathologist. Rarely, additional unsuspected lesions may be identified on the specimen radiograph, and proximity of the lesion to the margins may be suggested. However, it is important to recognize that the radiograph is a two-dimensional representation of a three-dimensional structure and therefore the status of the margins requires histologic evaluation. The surgeon is contacted following a review of the specimen radiograph. If the localizing wire is not seen on the specimen radiograph, the surgeon is asked if it was pulled during the surgical procedure. If the surgeon is unable to provide reassurance about the location of the wire, a follow-up mammogram is obtained 6 to 8 weeks following the surgery.

Patient 28

Figure 1.28. Screening study, 88-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, photographically coned views, right breast. Craniocaudal (C) and mediolateral oblique (D) views, photographically coned, right breast, screening study 8 years prior to (A) and (B).

 

What do you think, and what are the possible explanations?

A needle tip is present in the subcutaneous tissue. A biopsy marker is seen at this site on films done 8 years ago; its association with the needle tip on both images suggests the possibility that the needle tip is retained from a breast surgical procedure the patient had 30 years previously. Alternatively, the location of the needle tip at a prior biopsy site may be coincidental and not related to the surgery. Foreign bodies that can be seen in the breast include, but are not limited to, needle tips, sewing needles, lead pencil tips, bullets, bullet fragments, and buckshot. Patients are usually asymptomatic and unaware of the presence of a foreign body in their breast. Iatrogenic sources of foreign bodies include acupuncture needles, surgical clips following lumpectomy and axillary dissection, retained wire fragments following preoperative wire localizations, metallic markers placed to mark the site of a prior percutaneous needle biopsy, port-a-catheters, pacemakers, and retained Dacron cuffs from a Hickman catheter.

Patient 29

Figure 1.29. Screening study. Craniocaudal views.

What do you think of these images?

Why are the pectoral muscles sharply outlined by radiolucency?

The images are of fairly good quality, in that exposure and contrast are optimal; however, there are large skin folds inferiorly (at inframammary fold (IMF)/abdomen) simulating pectoral muscles. Air outlining the skin folds accounts for the radiolucency noted at the anterior edge of the folds. The tissue surrounding the skin folds should be evaluated carefully for blurring, because the skin folds may limit compression.

In positioning the breast for the craniocaudal projection, the technologist should identify the inframammary fold at its neutral position and lift the breast up from the inframammary fold as much as the natural mobility of the breast will allow. After lifting the breast, it is important to pull the breast out away from the chest wall and to tug on the lateral aspect of the breast as much as the natural mobility of the breast allows. As the breast is lifted, a skin fold can be created inferiorly if a portion of abdominal wall skin is lifted with the breast. Since this fold develops inferiorly, the technologist is unable to see it as she inspects the breast superiorly before the exposure is made. As in this patient, when this skin fold develops, it can simulate the pectoral muscle. Unlike the pectoral muscle, a sharp radiolucency (air) is seen abutting the skin fold.

 

Patient 30

Figure 1.30. Screening studies. Mediolateral oblique views.

What do you think?

Are these optimally positioned mediolateral oblique views?

The pectoral muscles are wide at the axilla. The anterior margin is slightly concave, but the muscles reach the level of the nipples. There are, however, large skin folds superimposed on the pectoral muscles posteriorly.

In positioning the breast for the mediolateral oblique projection, the angle of obliquity is determined by the orientation of the pectoral muscle. The breast and underlying pectoral muscle are then mobilized medially as much as possible. If care is not taken, a skin fold can develop laterally as the breast is mobilized medially. If the technologist looks at the medial aspect of the breast after compression is applied, she is unable to see the skin fold because it is up against the bucky and therefore is not apparent. The edge of the fold is outlined by air so a thin radiolucency is noted abutting the skin fold. A lymph node is incidentally noted, superimposed on the right pectoral muscle.

 

Patient 31

Figure 1.31. Screening study, 47-year-old woman. Craniocaudal (A) and mediolateral (B) oblique views. Craniocaudal views (C) photographically coned. Sternalis muscle (arrow).

 

Is this a normal mammogram, or do you think additional evaluation is indicated?

What BI-RADS® category would you use?

This is a normal mammogram. Skin folds are noted laterally on the craniocaudal (CC) views. These often develop as the technologist actively tugs on the lateral aspect of the breasts in an attempt to include as much lateral tissue as possible. Pectoral muscle can be seen posteriorly on the CC views. On the mediolateral oblique (MLO) views, the pectoral muscles are thick in the axillary region, extend to the level of the nipples, and have a convex anterior margin indicating excellent positioning technique.

Oh … you ask … what about the mass partially visualized at the posteromedial edge of the left breast on the CC view (Fig. 1.31C, arrow)? Where is this on the MLO view? This is the sternalis muscle, a normal variant. It is typically seen medially on craniocaudal views that include a maximum amount of posterior tissue (i.e., pectoral muscle is usually seen) and can have a variety of appearances. It is usually surrounded by fat and can be round in shape, as shown here, or it can be more triangular in shape. As in this patient, thin swirls of fatty tissue are seen in the “mass.” The oblique view is normal, as are any lateral views that may be obtained. Although it has been reported in as many as 8% of the population, based on cadaveric studies, the sternalis muscle is an uncommon finding on mammographic studies. It is more commonly unilateral, but can occur bilaterally and typically runs parasternally, from the infraclavicular area to the caudal aspect, lying anterior to the medial margin of the pectoralis major muscle.

No additional evaluation is indicated. BI-RADS® category 1: negative. Next screening mammogram is recommended in 1 year.

 

Patient 32

Figure 1.32. Right craniocaudal view, photographically coned laterally.

What is the observation?

When did this occur, before or after the exposure was made?

A curvilinear, plus-density artifact from a nail is present, reflecting improper handling or pressure on the film, after the exposure was made but before processing. If the film is palpated at this site, a crimp will be found corresponding to the artifact.

 

 

Patient 33

Figure 1.33. Craniocaudal (A) view, photographically coned. Mediolateral oblique (B) view, photographically coned.

What is the observation?

When did this occur, before or after the exposure was made?

Curvilinear, negative-density artifacts, from fingerprints, reflect improper handling or pressure on the films before the exposure was made. Films should always be handled by the edges.

 

Patient 34

Figure 1.34. Craniocaudal (A) view, photographically coned. Craniocaudal (B) view, photographically coned.

What observations can you make?

What happened?

On these images, a high-density artifact is present, surrounded by an area of blurring. This is consistent with poor film–screen contact. The artifact is on the screen and prevents the film from making direct contact with the screen. The blur surrounding the artifact reflects the lack of direct contact between film and screen. Depending on the size and shape of the artifact, the high-density material varies in size and shape and with it the surrounding area of blur. Unlike motion blur, this type of nonnsharpness is more localized, symmetric, and the area of blur is more geometrically marginated.

What is the recommendation with respect to the amount of time that should elapse between loading cassettes with film and making an exposure, and why is this recommended?

How often should screens be cleaned?

It is recommended that approximately 15 minutes be allowed to elapse between loading a cassette with film and making an exposure. This is so any entrapped air between film and screen can escape and good film–screen contact can develop. Screens should be cleaned at least weekly or immediately after dust artifacts are noted in an image by either the technologist or radiologist.

 

Patient 35

Figure 1.35. Screening study, 42-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

What is your observation?

These are nipple rings: They are used uni- or bilaterally and are variable in shape.

 

Patient 36

Figure 1.36. Craniocaudal view, right breast, photographically coned.

What is the observation?

Static results in fogging of the film in a fairly distinctive appearance and is related to the processor (as in this patient) or improper film handling.

 

Patient 37

Figure 1.37. A: Mediolateral oblique views, photographically coned. B: Mediolateral oblique views, photographically coned.

What is the observation?

High-density material observed bilaterally in the axilla simulating calcifications reflects the presence of deodorant. A prominent skin fold and an axillary lymph node are present, superimposed on the right mediolateral oblique view (Fig. 1.37B).

When a mammogram is scheduled, what instructions may be helpful for the patient in preparation for her mammogram?

Patients are asked to not apply deodorant prior to their mammogram. They are also advised to consider wearing a two-piece outfit (e.g., skirt and blouse or pants and blouse) to facilitate changing for the exam. If at the time of the mammogram the patient states that she is wearing deodorant, an attempt is made to have her wipe it clean before any images are taken. We provide spray deodorant in the dressing rooms for patients to use following their mammogram.

 

Patient 38

Figure 1.38. Screening study, 49-year-old woman. Craniocaudal (A, B) view. Screening study, 49-year-old woman. Mediolateral oblique (B) view. Mediolateral oblique (C) view, right breast, photographically coned. Calcified parasites.

 

How would you describe the findings, and what is the diagnosis?

What BI-RADS® category would you use?

Multiple clusters of coiled, serpiginous, linear and curvilinear calcifications are present bilaterally. These findings are consistent with calcified parasites. Several different parasites have been reported as occurring in the breast parenchyma or subcutaneous tissue (filariasis, loiasis, onchocerciasis, cysticercosis, dracunculosis, schistosomiasis, cutaneous myasis, etc). The dead parasites calcify, resulting in distinctive linear, curvilinear, coiled, lacelike, beadlike, or serpiginous calcifications scattered bilaterally. Sharply defined, round and punctate calcifications, limited to the pectoral muscles bilaterally, are seen in women with trichinosis.

BI-RADS® category 1: negative. Next screening mammogram is recommended in 1 year. BI-RADS® category 2: benign finding is used if the calcifications are described in the body of the report. Next screening mammogram is recommended in 1 year.

 

Patient 39

Figure 1.39. Screening study, 73-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Chest CT scan (C) confirms the presence of a lipoma in the right pectoral muscle (CT scan was done for reasons other than the lipoma).

 

What is your diagnosis?

Multiple axillary and intramammary lymph nodes are noted bilaterally, as are benign-type skin and vascular calcifications. A radiolucent mass is imaged in the right pectoral muscle consistent with a lipoma (Fig. 1.39C). The differential for radiolucent masses in the breast is limited and includes lipomas, oil cysts, and, rarely, galactoceles. Although ultrasound is not needed because the diagnosis is established mammographically, ultrasound is sometimes helpful in distinguishing between a lipoma and an oil cyst. Lipomas are often homogeneously iso- to slightly hyperechoic, well-circumscribed solid masses. Oil cysts have a variable appearance on ultrasound, ranging from cystic to complex cystic to solid masses, some with associated shadowing.

I-RADS® category 1: negative. Next screening mammogram is recommended in 1 year. BI-RADS® category 2: benign finding is used if the lipoma is described in the body of the report. Next screening mammogram is recommended in 1 year.

Lipomas are slow-growing tumors presenting as soft, discrete, round, single or multiple masses, most commonly in the subcutaneous tissues; however, they can develop anywhere, including in breast tissue, muscles, and internal organs. Rarely, they can be associated with hereditary multiple lipomatosis, adiposis dolorosa (Dercum disease), and Gardner syndrome. They are composed of mature adipocytes that may be surrounded by a fibrous capsule. Although most do not require treatment, steroid injections, liposuction, or surgery are options that have been described for their management.

 

Patient 40

Figure 1.40. Screening study, 63-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Mediolateral oblique (C) view, right breast, photographically coned. Sharp lucency consistent with air partially outlines the lobulated mass. Adjacent lucent-centered calcifications consistent with skin calcifications are noted. Craniocaudal (D) and mediolateral oblique (E) views taken 1 year prior to (A) and (B) with metallic wires used to mark prior biopsy sites and keloids. Mediolateral oblique (F) view, left breast, and craniocaudal (G) view, right breast, photographically coned. Metallic wires used to mark prior biopsy sites and keloids. The linear and curvilinear shape and sharply defined margins resulting from air surrounding the protuberant portion of the keloids are diagnostic. Associated lucent-centered calcifications consistent with skin calcifications are also noted.

 

What is your diagnosis?

Does this patient require any additional evaluation?

Multiple densities of various sizes and shapes, some appearing tubular, are seen bilaterally. Associated round, lucent-centered calcifications consistent with skin calcifications are also present. The margins of some of these densities are partially or completely outlined by a sharp lucency consistent with air (Fig. 1.40C). The sharply defined margins in conjunction with the shapes of these structures and the associated skin calcifications suggest that these may represent keloids forming at prior sites of surgery. Review of prior mammograms with markers placed at the prior biopsy sites confirms this impression (Fig. 1.40D–G). No further evaluation is indicated.

BI-RADS® category 1: negative. Next screening mammogram is recommended in 1 year. BI-RADS® category 2: benign finding is used if the keloids are described in the body of the report. Next screening mammogram is recommended in 1 year.

Wound healing is a complex process controlled by soluble mediators characterized by a fine equilibrium between the deposition and removal of structural proteins and glycoproteins. Disruption in these normal anabolic and catabolic processes can lead to abnormal wound repair and scar formation, including hypertrophic scars and keloids. Hypertrophic scars are raised but typically confined to the borders of the original wound and increase in size by expanding the margins of the scar not by invading surrounding tissue. They arise in the first 4 weeks following injury and are characterized by rapid growth followed by regression. The collagen fibers in hypertrophic scars are oriented parallel to the skin surface. In contrast, keloids extend beyond the borders of the original wound and involve the adjacent normal dermis. These lesions typically appear later, gradually progress, and can proliferate indefinitely; they do not regress. The collagen fibers in keloids are larger, thicker, wavier, and randomly distributed as compared to those found in hypertrophic scars. Hypertrophic scars and keloids are often familial and are associated with a higher incidence of occurrence in black and Hispanic patients.

Various theories have been advanced into the causes of keloid formation. These include increases in growth-factor activity (e.g., transforming growth factor and platelet-derived growth factor), alterations in the extracellular matrix, abnormal regulation of collagen turnover, mechanical tension on the healing wound, genetic factors leading to abnormal immune responses to dermal injury, and an immune reaction to sebum. Various treatments including steroid (triamcinolone) injections, surgery, radiation therapy, topical application of silicone gel, pressure therapy, laser, intralesional 5-fluorouracil, interferon, retinoids, calcium channel blockers, cryosurgery, and antihistamines have been tried. Results, however, have been mixed, and the treatment and management of patients with keloids remains a challenge.

 

 

Patient 41

Figure 1.41. Screening study, 60-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast.

 

What is your diagnosis?

Buck shot and bullet fragments with associated shrapnel are present in the left breast. Although the buck shot is distributed randomly, the bullet fragments and shrapnel demonstrate a more linear distribution, delineating the path of the bullets in the breast. No further intervention is warranted.

BI-RADS® category 1: negative. Next screening mammogram is recommended in 1 year. BI-RADS® category 2: benign finding is used if the metallic fragments are described in the body of the report. Next screening mammogram is recommended in 1 year.

Bibliography

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