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

Chapter 2 - Screening

 

Terms

·     Apocrine carcinomas

·     Artifacts

·     Axillary nodal metastasis

·     Batch interpretation

·     Biopsy changes

·     Breast cancer statistics

·     Call-back (recall) rates

·     Contrast

·     Craniocaudal views (CC)

·     Cysts

·     Diffuse changes

·     Distortion

·     Ductal carcinoma in situ (DCIS)

·     Exaggerated craniocaudal views laterally (XCCL)

·     Exposure

·     Fibroadenoma

·     Focal parenchymal asymmetry

·     Global parenchymal asymmetry

·     Invasive ductal carcinoma, not otherwise specified (NOS)

·     Invasive lobular carcinoma

·     Isolated tumor cells

·     Kilovoltage peak (kVp)

·     Lymphovascular space involvement

·     Mediolateral oblique views (MLO)

·     Micrometastasis

·     Milliamperage output (mAs)

·     Mondor disease

·     Ninety-degree lateromedial views (LM)

·     Ninety-degree mediolateral views (ML)

·     Poland syndrome

·     Posterior nipple line (PNL)

·     Reduction mammoplasty

·     Quantum mottle

·     Shrinking breast

·     Screening guidelines

·     Screening views

·     Sharpness

·     Triangulation

Introduction

Mammography can demonstrate clinically occult breast cancers. Is this significant? Does this make a difference? Does finding clinically occult cancers affect overall mortality from breast cancer? Yes, yes, and yes. Support for the routine use of screening mammography is provided by results from seven of eight randomized controlled trials in large populations of women, including 40- to 49-year-old women. These studies demonstrated a 20% to 32% reduction in breast cancer mortality among the women invited to undergo screening mammography. Updates from the two-county Swedish trial have reported 20-year survivals of 87.3% and 83.8% among women identified with tumors <0.9 cm and 1.0 to 1.4 cm in size, respectively. The goal of screening mammography (and our job), therefore, is to consistently identify breast cancers that are <1.4 cm (ideally, <0.9 cm). It is noteworthy that the most common method of breast cancer detection is now screening mammography (as opposed to breast self-examination), and that mortality rates from breast cancer continue to drop.

Based on the scientific evidence and expert opinion available, an independent panel of 42 medical and scientific experts developed new breast cancer screening guidelines that were adopted and published by the American Cancer Society (ACS) in 2003. The ACS recommends annual screening mammography starting at age 40 years and continuing for as long as a woman is in good health. Clinical breast exams should be part of a periodic health exam about every 3 years for women in their 20s and 30s and annually for women aged 40 years and older. Women should report any breast change they detect promptly to their health care provider. Beginning in their 20s, women should be told about the benefits and limitations of breast self-examination (BSE). It is acceptable for women to choose not to do BSE or to do it only occasionally. Women known to be at increased risk (e.g., personal or strong family history of breast cancer, a genetic tendency or prior mediastinal radiation therapy for Hodgkin lymphoma) may benefit from earlier initiation of early-detection testing, screening at shorter intervals, and/or the addition of breast ultrasound or magnetic resonance imaging (MRI). Indeed, since 2003, several reports have supported the use of MRI for the detection of small cancers in high-risk women.

It was estimated that 211,240 new cases of breast cancer would occur in 2005 among women in the United States. Among men, 1,690 new breast cancer cases were expected in 2005. The estimated numbers of deaths resulting from breast cancer in 2005 among women and men were 40,410 and 460, respectively. A decline in the mortality rate from breast cancer of 2.3% per year from 1990 to 2000 has been reported among all women, with larger decreases in women under age 50 years. The decline in the mortality rate is attributed to earlier detection and improved treatment.

Screening Views

Craniocaudal (CC) and mediolateral oblique (MLO) views are the standard screening views. In addition to routine views, our technologists obtain anterior compression and exaggerated craniocaudal (XCCL) views, as needed, to tailor the screening study to the individual woman.

Interpretation

Compared to online reading, batch interpretation of screening mammograms is cost-effective and efficient. With batch interpretation, the patient leaves the imaging facility after her routine views are done and reviewed by the technologist for technical adequacy. The mammograms are hung on high-luminance, dedicated mammography multiviewers for interpretation by the radiologist at a later time. At our facility, right and left CC and right and left MLO views are hung back to back. The two CC views are placed side by side with the two MLO views. If they are available, films from 2 years before are hung above the current study for comparison. Subtle changes may not be apparent from one year to the next, but may be more easily perceived if a study other than the one from 1 year ago is used for comparison. However, before calling a patient back for a diagnostic study, reviewing the mammogram from the year before is often helpful to make sure the current area of concern was not evaluated last year. Any additional studies done at our center are kept in jackets close to the multiviewer so that they can be reviewed as deemed necessary by the interpreting radiologist.

Figure 2.1. Image evaluation. On craniocaudal views, narrow the search for potential lesions by splitting the images in thirds. This will help you to focus attention on smaller amounts of tissue. Go back and forth between the right and left craniocaudal views, looking specifically for asymmetries, possible masses, distortion, or calcifications.

In evaluating screening mammograms, I recommend developing a viewing strategy that is systematic and is used consistently. I also think it is important to have a proactive and focused mindset when reviewing studies, rather than waiting passively for more subtle findings to become apparent. In other words, send your eyes out looking for potential lesions in specific locations; otherwise you may miss subtle findings or study limitations (e.g., blurring) that may preclude detection of possible abnormalities. Chance favors a prepared mind. Ideal viewing conditions are equally important. All extraneous light should be eliminated so that the only light in the room is coming through the films being reviewed. Paper work and interruptions should be minimized.

Whatever approach you use, it should begin with a review of the films for technical adequacy. Specifically, is positioning acceptable? Has any tissue, and possibly a lesion, been excluded from the films (e.g., do you see tissue at the edge of any of the films)? Is glandular tissue adequately compressed and penetrated (exposed)? Are the films high in contrast? Are there any artifacts that may preclude adequate interpretation? Is there any blurring?

Look for diffuse changes that may be difficult to perceive, particularly if you are focused on detecting smaller potential lesions. Is one breast larger or more dense than the other? Don't assume that the larger breast is the abnormal breast; the smaller breast may be progressively “shrinking.” Are the technical factors needed for adequate exposure of one breast significantly different from those used to expose the contralateral side? Is compression limited (e.g., centimeters of compression or decanewtons used)? Is there prominence of the trabecular markings? Do you see trabecular markings superimposed on the pectoral muscles (e.g., reminiscent of “kerley” B lines)? Are there any findings in the axillary regions?

After evaluating the mammogram globally for technical adequacy and diffuse changes, look specifically both with and without a magnification lens for masses, areas of asymmetry, architectural distortion, and calcifications. Narrowing the search is helpful in focusing your review. On CC views, look at the lateral, middle, and medial thirds of the breasts (Fig. 2.1). On MLO views, evaluate the upper, middle, and lower thirds of the breasts (Fig. 2.2). Search out potentially abnormal areas as you go back and forth between the right and left breasts. Also, evaluate fat–glandular interfaces specifically for straight lines or convex tissue bulges, the fatty stripe of tissue between the pectoral muscle and glandular tissue on MLO views, the superior cone of tissue on MLO views, the subareolar areas, and the medial portions of the breasts on CC views (Fig. 2.3).

Figure 2.2. Image evaluation. On mediolateral oblique views, narrow the search for potential lesions by splitting the images in thirds. This will help you to focus attention on smaller amounts of tissue. Go back and forth between the right and left mediolateral oblique views, looking specifically for asymmetries, possible masses, distortion, or calcifications.

After formulating a working hypothesis on a given mammogram, compare it with prior studies and look at the history form for potentially relevant factors (hormone replacement therapy, prior breast surgery, family history of breast cancer, skin lesions etc.). Be careful not to let prior films influence decisions regarding the relevance of a finding on the current study. In some women, it is important to look at several comparison studies. If you perceive an area of spiculation or distortion that cannot be explained by a history of surgery, trauma, or mastitis at that specific site, the patient should be evaluated in spite of apparent stability. Stability of a lesion does not assure that it is benign.

Make no assumptions. If you assume something is benign or malignant, it becomes very difficult to think otherwise. Also, if there is an obvious finding, make a conscientious effort to look at the remainder of the mammogram first. Do not focus your attention on obvious findings to the exclusion of other subtle, and potentially more significant, findings.

On screening studies, my goal is to detect potential abnormalities. I make no particular effort to characterize potential or true lesions on screening studies. Over the years it has become apparent to me that sometimes what I think is a significant lesion on the screening mammogram turns out to be insignificant after additional evaluation and what I initially think is almost certainly benign is cancer. Similarly, in some patients, what is seen on the screening studies turns out to represent a more extensive lesion (“the tip of the iceberg”). Why make decisions with insufficient and potentially misleading information? Why work with low confidence? Additional evaluation increases certainty in making appropriate recommendations and narrows differential considerations to one or two options. Recommendations are more easily justified following complete and thorough evaluations. With the confidence generated by the additional evaluation, succinct, definitive, and directive reports can be generated.

Management of Patients Needing Additional Evaluation

For women with an obvious lesion on the screening study, additional evaluation helps characterize the extent of the lesion and sometimes establishes the presence of other, initially unsuspected, lesions. It provides an opportunity to communicate directly with the patient and undertake imaging-guided biopsies at the time of call-back. In essence, we expedite patient care. Consequently, the only BI-RADS® assessment categories I use on screening studies are category 1 (negative), category 2 (benign finding), and category 0 (needs additional imaging evaluation or needs prior mammograms for comparison).

Category 0 is used when additional studies are indicated or when prior studies are to be requested and comparison is needed to make a final assessment. For those women in whom a potential abnormality is detected, we categorize the call-back as level 1, 2, or 3. These levels are used internally to indicate the amount of time that should be allotted for the patient's diagnostic appointment. Fifteen, thirty, and sixty minutes are allowed for level 1, 2, and 3 call-backs, respectively. In general, level 1 designates those patients for whom physical examination, additional mammographic images, or an ultrasound are all that should be needed to resolve the question. If the interpreting radiologist expects that a patient will need additional mammographic images and an ultrasound, the call-back is designated as level 2. When the radiologist expects that the patient will need a biopsy, level 3 is used so that an adequate amount of time is available to do a biopsy when the patient returns for additional evaluation. Although this is an arbitrary classification, characterized by times when, after completing the evaluation, a level 1 call-back patient requires a biopsy and a level 3 call-back patient does not, the system works well. It provides for more efficient use of the schedule and allows us to complete evaluations in one visit. It has enabled us to optimize patient care in a practical and cost-effective manner.

Figure 2.3. Image evaluation. A: On the craniocaudal views, evaluate areas where breast cancers are likely to develop—specifically, the medial quadrants, subareolar areas, fat-glandular interfaces, and the retroglandular areas posteriorly. B: On the mediolateral oblique views, evaluate areas where breast cancers are likely to develop—specifically, the fatty stripe of tissue between the pectoral muscle and glandular tissue, the superior cone of tissue, subareolar areas, and the inferior aspects of the breasts.

At the time of the screening study, the technologist informs the patient about the possibility of a call-back for further evaluation. In addition, each woman is given a written statement that describes the process for reviewing her mammogram, issuing a report to her doctor, sending her a letter with results, and the possibility of being called back for a diagnostic evaluation. It is important for women to be informed of the process and to know that being called back does not necessarily mean they have cancer. Our goal is to minimize some of the anxiety experienced by patients when they are called back for additional evaluation. It does not always work, but it does help some women.

All women who require additional evaluation are contacted directly by a member of our staff. By communicating with the patient directly, we can explain the reason for the call-back more appropriately than others might (e.g., as opposed to having a referring physician's office tell the patient that the first images taken were no good), and we reassure the patient regarding the need for additional studies. This method also expedites patient care by decreasing the amount of time needed to schedule the diagnostic evaluation. If we are unable to contact the woman by phone within 48 hours following her screening study, we send a letter via regular mail asking her to call us. If after a week from mailing the letter we still have not heard from the patient, a certified letter is mailed to her with a copy to the referring physician. All efforts to communicate with the patient are documented in her chart.

A report is generated for all studies in which a prior mammogram is requested and comparison is needed to make a final assessment. These reports are assigned to a category “0”; we do not keep undictated studies aside pending arrival of comparison films. By generating a report, the referring physician is informed that we are working on obtaining prior studies and a system to track the patient is set in motion that minimizes the likelihood of a patient “falling through the cracks.” We allow a 2-week interval during which we make every effort to locate prior studies; this includes calling the facility indicated by the patient on her history form. If this action is unsuccessful, we contact the referring physician and request prior mammogram reports that will indicate the name of the facility and the date of the prior study. Lastly, we sometimes call the patient to verify the information she provided. If we are unable to obtain prior films after 2 weeks, an addendum to the initial report is issued and we dictate the findings as though there were no prior studies. Every effort we make to procure prior studies is documented in the patient's file.

Call-Back Rates

What is an appropriate call-back (recall) rate? This is an important question to consider and is something radiologists involved in screening mammography should monitor routinely. Calling a patient back for diagnostic evaluation is not innocuous and should never be trivialized. In some women, it is associated with significant morbidity that at times is (unfortunately) grossly underestimated. Regardless of how much you try to prepare a woman for the possibility of a call-back, it is guaranteed to provoke anxiety and stress in most women. High recall rates are also associated with increased costs and decreased efficiency of screening programs. Counter this with our goal of never missing an opportunity to diagnose an early breast cancer. Undoubtedly, to call back or not is a fine line that needs to be considered carefully. Depending on the availability of prior films, you can expect call-back rates to be higher among women with no prior studies compared to those women in whom prior films are available. In considering the call-back rate for individual radiologists, I think it is important not to consider this a static figure but rather a work in progress. Early in the career of a radiologist one should expect and accept higher call-back rates. However, the rate should decrease progressively with the number of screening mammograms evaluated over time. Although it is inconvenient and not usually easy to schedule, the ideal learning situation is for the radiologist recommending the call-back to be the one involved in the diagnostic workup. Under these circumstances, meaningful call-back rates can be generated and improvement shown over the years. It is also important to recognize that most call-backs for diagnostic evaluations do not lead to biopsies. Based on published reports, the American College of Radiology recommends that call-backs be maintained at a rate of 10% or less.

Conclusion

In this chapter, the screening mammogram is the starting point for all patients discussed. Focus your attention initially on systematically reviewing the images as described above. Determine if the mammogram is normal or potentially abnormal. Some differentials are included, and pathology results are provided for those patients for whom biopsy is appropriate. I also need to state the obvious at the onset of this chapter: What I present is an artificial situation. For didactic purposes, I have presented a significant number of patients with breast cancer in this chapter; in a true screening program, most of the mammograms you review are normal.

 

Patient 1

Figure 2.4. Screening studies. Mediolateral oblique (A) and craniocaudal (B) views. Mediolateral oblique (C) views with suboptimal positioning. Although the pectoral muscles are thick at the axilla, the anterior margins are not convex and they do not extend to the level of the nipple. The shape of the muscles is triangular. Repeat mediolateral oblique (D) views, using optimal technique, show thick pectoral muscles at the axilla with convex anterior margins extending to the level of the nipples. Posterior nipple line. E: The posterior nipple line (PNL) is measured when it is suspected that posterior tissue is excluded on a craniocaudal (CC) view. It is most useful when positioning on the corresponding mediolateral oblique view is optimal. A line (1) can be drawn to delineate the anterior margin of the pectoral muscle. The PNL (2) is a perpendicular line drawn from the nipple to the anterior edge of the pectoral muscle. The PNL is measured. This measurement provides an estimate of the amount of tissue that should be included on the CC views. F: On the CC view, the PNL extends from the nipple to the edge of the film. The measurement of the PNL on the CC view should be within 1 cm of that measured on the MLO view. Craniocaudal (G) and mediolateral oblique (H) views. Mediolateral oblique (I) and craniocaudal (J) views showing the posterior nipple line measurements. An inadequate amount of tissue is included on the right craniocaudal view. Repeat right craniocaudal (K) view. Fat is now seen at the edge of the film. Repeat right craniocaudal (L) view with the posterior nipple line measuring 10 cm, which is comparable to that measured on the original mediolateral oblique view.

 

In assessing images for technical adequacy, what factors should you evaluate?

The technical factors you should evaluate before focusing on potential abnormalities include positioning, compression, exposure, contrast, sharpness, noise, artifacts, and film labeling. As an interpreting radiologist, you are the gatekeeper for image quality and overall patient care at your facility. If you are willing to routinely interpret suboptimal studies without a good explanation that is well documented (a patient with Parkinson's disease, a frozen shoulder, history of stroke, etc.), you are basically willing to accept a potential delay in the diagnosis of breast cancer. The overall quality bar at your facility will be as high as you set it.

In evaluating positioning on mediolateral oblique (MLO) views, the pectoral muscles should be wide in the axillary regions, extend to the level of the nipples, and have convex margins anteriorly. The breast needs to be lifted (e.g., not sagging or drooping) so that the inframammary fold is open and a small amount of upper abdomen is included on the image (Fig. 2.4A). As the technologist positions the breast, she needs to establish the angle of obliquity of the patient's pectoral muscle; it is easier to mobilize tissue maximally away from the body if it is pulled parallel to underlying muscle fibers. Using the appropriate angle for the patient and having the patient lean in slightly to relax the muscle, the technologist needs to mobilize the breast and muscle medially as much as possible and maintain the medial mobilization of the breast as compression is applied and the breast is lifted up and pulled out. If an incorrect angle of obliquity is selected, the breast is not mobilized as much as possible medially, or if the patient moves out of the unit as compression is applied, the pectoral muscle may not be thick at the axilla, extend to the level of the nipple, or it may have a concave margin, a triangular shape, or be parallel to the edge of the film (Fig. 2.4C).

 

Positioning

In positioning patients for craniocaudal views, the technologist needs to identify the inframammary fold and lift the breast as much as the natural mobility of the breast permits. Next she needs to pull the breast tissue out and actively tug on the lateral aspect of the breast so as to include as much posterolateral tissue as possible. On craniocaudal (CC) views, you should expect to see pectoral muscle in 30% to 40% of patients. When you see pectoral muscles on the CC views, you can be assured that posterior tissue has been included on the images (Fig. 2.4B). If pectoral muscle is not seen on the CC view, look for cleavage as an indication that medial tissue has not been excluded from the image. If no pectoral muscle or cleavage is seen, measure the posterior nipple line (PNL) on the MLO view and compare it with the measurement on the CC view (Fig. 2.4E, F). The measurements should be within 1 cm of each other. Also, evaluate the lateral aspect of the images. If there is tissue extending to the edge of the film, the technologist did not pull lateral tissue in, or an exaggerated craniocaudal view laterally (XCCL) may need to be done to evaluate the patient adequately in the craniocaudal projection.

 

 

What are your observations concerning the positioning on this patient's mammogram?

Retroglandular fat is seen laterally on the left craniocaudal view. Tissue is seen extending to the edge of the film on the right craniocaudal view, and although the right breast is smaller than the left, is there an adequate amount of posterior tissue on the right craniocaudal view? How can you determine this? Measuring the PNL is helpful in assessing if the amount of tissue imaged on the craniocaudal view is adequate (Fig. 2.4I, J). In this patient, the PNL measurement on the right MLO view is 10 cm, compared to 7.2 cm on the right CC view. A significant amount of posterior tissue is excluded from the right CC view and therefore it needs to be repeated. Focusing on technique, a repeat CC view (Fig. 2.4K) is obtained and demonstrates a significantly greater amount of tissue. There is now fat at the edge of the film and the PNL measurement on this second CC view (Fig. 2.4L) is 10 cm, which is equal to what is measured on the MLO view. If images that are missing 2.8 cm of posterior tissue (as on the original right CC view in this patient) are accepted and interpreted, our goal of finding cancers that are less than 1 cm in size is compromised significantly.

In addition to positioning, compression needs to be assessed by specifically evaluating the images for uneven or inadequate exposure, motion blur, and poor separation of parenchymal densities.

Additional Technical Factors to Assess

Glandular tissue needs to be adequately exposed so that there is visualization of trabecula, small tubular structures, and vessels. In many women, adequate penetration of the glandular tissue overexposes the skin and subcutaneous tissue. Image contrast is also important. Ideally, contrast is maximized so that subtle density differences in glandular tissue can be appreciated. Subcutaneous and retroglandular fat is dark gray or nearly black in high-contrast images. Poor-contrast images are characterized by dull gray retroglandular and subcutaneous fat, and the skin is readily apparent.

Sharpness needs to be evaluated by looking specifically for blurring (i.e., unsharpness). The most common cause of blur is patient motion. This is why adequate breast compression is critical. Short exposures (ideally, <2 s) are also helpful in minimizing motion blur. Motion blur does not always involve the entire image. It can be localized to one area on the mammogram, where it is commonly caused by lack of uniformity in breast compression. Poor film screen contact can also be a cause of localized unsharpness. Sharpness is also affected by focal spot size, object-to-image distance, and source-to-image distance. Increases in focal spot size and object-to-image distance as well as decreases in source-to-image distance contribute to geometric unsharpness.

The ability to detect small structures such as calcifications is decreased by noise (e.g., radiographic mottle). Quantum mottle is the major cause of noise in mammography. Noise can be identified on an image by a background density that is not homogeneous and results in loss of sharpness and visualization of low-contrast structures.

Artifacts can result from x-ray equipment (filter, compression paddle, image receptor holder, grid, etc.), patient factors (deodorant, hair, jewelry, tattoos, etc.), and cassette, film, and screen factors (upside-down cassette in bucky, film scratches, dents, fingerprints, pick-off, moisture, incorrect film loading so that the emulsion side is away from the screen, fog, static, foreign objects on the screen, etc.). Ideally, most images are artifact free. Depending on the overall effect on image quality, films with artifacts may need to be repeated.

With respect to film labeling, the following information is required on all films: patient name, unique patient identification number, date of study, radiopaque laterality and projection markers placed closest to the axilla, facility name, facility location (city, state, and Zip code), technologist identification, cassette/screen identification number, and mammography unit identification number if there is more than one unit in the facility.

 

Patient 2

Figure 2.5. Screening study, 43-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

How would you describe the findings on this mammogram?

Compared to the left breast, the right breast is smaller, with dense, asymmetrically distributed tissue (i.e., global parenchymal asymmetry). Although breast size and tissue are commonly symmetric, asymmetries in breast size and tissue distribution can be seen in numerous women as a normal variant. No mass or distortion is noted in the area of increased tissue on the right. The tissue in the right breast is scalloped and contains areas of fatty lobulation. A solitary dense dystrophic calcification is present in the right breast.

What two pieces of information are critical in this patient?

In this woman, it is important to determine that there is no palpable abnormality in the right breast and that the asymmetry in size (either a decrease in size on the right or an increase in size on the left) is not a new or developing change. If they are available, comparison with multiple prior studies is critical, as is a history of prior right breast surgery or trauma. If there is any question about a corresponding palpable abnormality or a progressive change in breast size, the patient can be asked to return for correlative physical examination and, if needed, additional mammographic views, ultrasound, or, occasionally, magnetic resonance imaging. When they are abnormal, asymmetric changes may be the result of chest wall trauma (e.g., burns), congenital abnormalities (e.g., Poland syndrome), or surgery. Invasive ductal carcinomas can present with global areas of parenchymal asymmetry, but these are usually clinically apparent and readily palpable. Invasive lobular carcinoma can also present with global areas of parenchymal asymmetry and progressive changes in breast size (either increases or decreases); palpable findings may be present, but they are often more subtle in patients with invasive lobular carcinomas. Rarely, lymphoma can present with diffuse, asymmetric involvement of one breast.

What do you think about the amount of posterior tissue imaged on the right craniocaudal view?

What BI-RADS® category would you assign?

Are you sure?

Pectoral muscle and retroglandular fat are imaged on the right craniocaudal view and there is no tissue extending to the edge of the film, so it is unlikely that posterior tissue has been excluded from the image.

No change is noted in comparing with multiple prior studies (not shown).

This is categorized as BI-RADS® category 1: negative. BI-RADS® category 2: benign finding can be used if the observations are described in the report. Annual screening mammography is recommended.

 

Patient 3

Figure 2.6. Screening study, 81-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)views. The distance to the possible lesion is measured from the nipple as “X” cm on the craniocaudal (CC) view. As “X” cm is measured back from the nipple on the mediolateral oblique (MLO) view, an arc can be created that describes the approximate location for the possible lesion noted in the right CC view. No comparably sized area is identified in the MLO view. Intramammary lymph nodes described above are within the circles on the images.

 

What do you think of the positioning on the craniocaudal (CC) views?

What BI-RADS® category would you assign, and what is your recommendation?

Patient positioning in this study is acceptable. Although no pectoral muscle is seen on the craniocaudal views, cleavage is seen medially and there is retroglandular fat bilaterally (i.e., no tissue is seen at the edge of the films). A lymph node is noted superimposed on the left pectoral muscle, and one is seen laterally on the right craniocaudal view.

What do you think of the rounded area of asymmetric tissue laterally in the right breast?

Do you see a potential abnormality of comparable size, shape, and density when you evaluate the mediolateral oblique (MLO) view? Based on the location of this area on the CC view, look specifically at where you would expect to find the corresponding area on the MLO view. Using the distance of this area from the nipple on the CC view (Fig. 2.6C), generate an arc on the MLO view (Fig. 2.6D) to help you approximate the expected location of this area on the MLO view.

With the exception of some invasive lobular carcinomas, most breast cancers are three-dimensional structures with comparably sized and shaped abnormalities on any view of the breast. In this woman, there is no comparable area in size, shape, or density on the MLO view. For potential lesions >1 cm in size noted on one view, a comparable abnormality should be identified on the other projection at approximately the same distance from the nipple.

BI-RADS® category1: negative. Annual screening mammography is recommended.

 

 

Figure 2.7. Screening study, 45-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

Patient 4

 

What do you think?

What BI-RADS® category would you assign, and what is your recommendation?

A rounded, asymmetric island of tissue is noted laterally in the left breast. However, in evaluating the mediolateral oblique view, no comparably sized or shaped area is identified that would correspond to the approximate location of this area on the craniocaudal view. Relatively low-density tissue is seen superiorly, characterized by scalloping, interposed fat, and a gradual transition in density. As illustrated here, asymmetric tissue is often planar (i.e., best seen in one projection and changes significantly in appearance on other views), scalloped, heterogeneous in density because of interspersed fat, and characterized by a gradual change in density at the margins. Masses are three-dimensional, with an abrupt change in density and a bulging (convex) margin. True lesions, particularly when >1 cm, are of comparable size, shape and density on the two standard projections and are at approximately the same distance from the nipple on the two views.

BI-RADS® category 1: negative. Annual screening mammography is recommended.

Figure 2.8. Initial screening study, 41-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D) spot compression views.

Patient 5

 

What do you think?

What BI-RADS® category would you assign, and what is your recommendation?

A focal area of parenchymal asymmetry is present in the upper outer quadrant of the left breast. It is of comparable size and density and is at the same approximate distance from the nipple on the two projections. Differential considerations include normal variant, hormone replacement therapy effect, asymmetry secondary to prior surgical excision of the corresponding tissue in the right breast, focal fibrosis, pseudoangiomatous stromal hyperplasia (PASH), posttraumatic changes (evolving hematoma, fat necrosis), mastitis, fibroadenolipoma (hamartoma), invasive ductal carcinoma not otherwise specified, invasive lobular carcinoma, and lymphoma.

If, as in this woman, no prior studies are available for comparison, spot compression views and possibly ultrasound with correlative physical examination can be undertaken to exclude an underlying malignancy.

BI-RADS® category 0: need additional imaging evaluation.

What do you think of this predominantly fatty pattern in a 41-year-old woman?

Although it is routinely suggested that mammography in young women is not very good because dense tissue precludes the detection of breast cancer, it is clear that age alone cannot be used to establish the density of the parenchymal pattern in an individual woman. Regardless of childbearing, young women can have completely fatty tissue and older, postmenopausal women can have dense tissue. It is also important to recognize that there is large intra- and interobserver variability in the application of arbitrarily defined parenchymal patterns. Additionally, the perceived density of a tissue pattern is dependent on technical factors. Some “extremely dense” tissue is inadequately exposed fibroglandular tissue.

What do you think now?

What BI-RADS® category would you assign at this point, and what is your recommendation?

Normal tissue is imaged on the spot compression views. The overall appearance and density of this tissue is different in the two projections; there is scalloping and fatty tissue is interspersed with the glandular tissue. There is a gradual change in density at the margins. In contrast, masses are three-dimensional with comparable size and density regardless of projection. They are also characterized by an abrupt change in density at the margins. The patient has no history of breast surgery and recalls no trauma to the left breast. Physical examination of this area is normal and symmetric with the comparable site on the contralateral breast. No tenderness is elicited. Ultrasound demonstrates normal tissue throughout the upper outer quadrant of the left breast. This is benign focal parenchymal asymmetry, a normal variant.

BI-RADS® category 2: benign finding. Annual screening mammography is recommended.

 

Patient 6

Figure 2.9. Screening study, 68-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Mediolateral oblique (C) and craniocaudal (D)photographically coned views. Architectural distortion readily apparent on the mediolateral oblique view, more subtle on the craniocaudal view.

 

How do you evaluate a screening mammogram?

The evaluation of screening mammograms can be approached in different ways. Develop a strategy that is systematic and use it consistently. Take a proactive approach, and actively send your eyes and brain looking for particular abnormalities in specific locations (subareolar area, medially on craniocaudal views, etc.). This helps you stay focused and minimizes the likelihood that you will miss significant findings. Whatever approach you settle on, it should include a review of the films for technical adequacy. Specifically, is the positioning acceptable? Has tissue and possibly a lesion been excluded (e.g., do you see tissue to the edge of any of the films)? Is glandular tissue adequately compressed and penetrated? Are the films high in contrast? Are there any artifacts that may preclude adequate interpretation of the films? Is there any blurring? Before focusing on perceiving localized findings, look for global or diffuse changes. These may be difficult to appreciate once you focus your attention on more subtle findings.

After evaluating the mammogram at a distance for technical adequacy and diffuse changes, look specifically (with and without a magnification lens) for masses, focal areas of asymmetry, architectural distortion, and calcifications. It is helpful to narrow your search, so on craniocaudal (CC) views, focus on the lateral, middle, and medial thirds of the breasts (Fig. 2.1). On the mediolateral oblique (MLO) views, focus on the upper, middle, and lower thirds of the breasts (Fig. 2.2). Search out potentially abnormal areas as you go back and forth between the right and the left breasts. Specifically, evaluate fat/glandular interfaces, the fatty stripe of tissue between pectoral muscle and glandular tissue on MLO views, the superior cone of tissue on the MLO views, subareolar areas, and the usually fatty tissue medially on CC views (Fig. 2.3). After developing a working hypothesis on a given mammogram, compare with prior studies and look at the history form for any pertinent information (family history of breast cancer or ovarian cancer, estrogen use, prior trauma or surgery, etc.).

What do you think?

In this patient, scattered dystrophic calcifications are present bilaterally. Did you find a potential abnormality? If you did not, look specifically for architectural distortion and move to the subareolar areas. Architectural distortion is present in the right subareolar area, best seen on the MLO view (Fig. 2.9C); it is not readily apparent on the CC view (Fig. 2.9D). Is it safe to assume that this is cancer? No! Benign-appearing lesions can turn out to be cancer, malignant-appearing lesions can reflect benign changes. Make no assumptions, or you will pigeonhole yourself and limit your ability to think through the possibilities. Most findings in the breast have benign and malignant etiologies in the differential. Our job is to sort through the possibilities accurately and efficiently.

What is your differential for architectural distortion?

Among the benign possibilities, consider fat necrosis related to trauma or prior surgery, mastitis, complex sclerosing lesions (sclerosing adenosis), papilloma, and focal fibrosis (rare). Invasive ductal carcinoma not otherwise specified (NOS), tubular carcinoma, ductal carcinoma in situ (rare), and invasive lobular carcinoma are among the invasive lesions that may present with architectural distortion. Armed with differential considerations, you can sort through them by integrating the imaging features of the lesion in question with the patient's age, pertinent history, and physical examination. If you develop and routinely follow a simple, logical, and systematic approach, the next appropriate step becomes readily apparent and is justifiable. This approach is rarely misleading.

What, if any, history would keep you from calling this patient back?

What BI-RADS® assessment category would you assign, and what is your recommendation?

In this patient, the overall characteristics of the lesion include long spicules, no significant central density, and a more pronounced appearance in one of the two routine views. It is critical to establish if the patient has had a biopsy (or significant trauma) in the right subareolar area. If there is a history of prior surgery, the location of the surgical procedure has to correspond directly to the area of distortion. Don't hesitate to examine the patient to establish the presence of a subtle periareolar scar even when the patient does not recall a prior breast biopsy. A complex sclerosing lesion is a good possibility in a woman with this type of lesion and no history of surgery or apparent scar on physical examination. Complex sclerosing lesions are often seen better in one projection and, given their size, usually have no corresponding palpable abnormality on physical examination. In considering mastitis, the breast is usually tender; there may be associated erythema and warmth as well as a history of prior inflammatory changes in the subareolar area.

In thinking about the malignant possibilities, an invasive ductal carcinoma (NOS) of this size and in this location will almost certainly have physical findings, including a palpable abnormality, dimpling, and possibly nipple retraction. Tubular carcinomas are usually fairly small and are more commonly identified in younger women (in their 40s). Invasive lobular carcinomas are more common in older patients, and physical findings are often subtle.

This patient has had surgery in the right subareolar area corresponding to the site of distortion. The findings reflect fat necrosis related to the prior biopsy. Architectural distortion related to prior surgery is often planar and therefore better seen in one projection, as in this patient. No additional evaluation is indicated.

BI-RADS® category 2: benign finding. Annual screening mammography is recommended.

 

 

Patient 7

Figure 2.10. Screening study, 68-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)spot compression views, right breast. Ultrasound image (E), radial (RAD) projection of the lesion. Ultrasound image (F), radial (RAD) projection. The lesion is contained in the box.

 

What do you think?

What BI-RADS® assessment category would you assign, and what is your recommendation?

There are arterial calcifications bilaterally. Did you notice a mass in the right breast? This is new compared with prior studies (not shown). Additional evaluation is recommended. BI-RADS® category 0: need additional imaging evaluation.

Do you have any additional observations?

Technically, are you happy with this study?

Be specific in describing the problem

Positioning on this study is not optimal. There is insufficient pectoral muscle on the mediolateral oblique (MLO) views. Ideally, pectoral muscle should be seen to the level of the nipple; it should be thick in the axilla and have a convex anterior margin. Given the triangular shape of the muscle in this patient, several things went wrong during positioning. It is likely that an incorrect angle of obliquity was selected, the muscles were not relaxed, and the breasts were not adequately mobilized medially (or if they were, the patient pulled out during positioning).

On the craniocaudal (CC) views, a significant amount of posterior tissue is excluded from the images. In determining if an adequate amount of tissue has been included on the CC views, look for pectoral muscle posteriorly or for cleavage medially. If neither of these is seen, measure the posterior nipple line (PNL) on the MLO views (and remember that in this patient, positioning on the MLO views is not optimal, so the PNL measurement is not an optimal measure of the amount of tissue this patient has) and compare it to that measured on the CC views (Fig. 2.4E, F). The PNL measurement on the CC view should be within 1 cm of that measured on the MLO view. It is not in this patient. Additionally, if you look at the length of the calcified artery laterally on the right CC and the relationship of the lesion to the edge of the film between CC and MLO views, it is clear that posterior tissue has been excluded on the CC views.

 

What do you think?

How would you describe the finding, and at what clock position would you expect to find this lesion?

The spot compression views confirm the presence of a 1-cm irregular mass with spiculated margins. A biopsy is indicated based on the mammographic findings.

An irregular, hypoechoic mass with angular margins is imaged at the 11 o'clock position, 6 cm from the right nipple, corresponding to the expected location of the lesion seen mammographically.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered. An ultrasound-guided core biopsy is done at the time of the diagnostic evaluation.

A poorly differentiated, invasive ductal carcinoma is reported histologically following the ultrasound guided core biopsy. A 1.2-cm, grade III, invasive ductal carcinoma is reported on the lumpectomy specimen. No metastatic disease is identified in four excised sentinel lymph nodes; [pT1c, pN0(sn)(i—), pMX; Stage I].

 

Patient 8

Figure 2.11. Screening study, 51-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. The metallic BB on the left is on a skin lesion. No history of breast surgery or significant trauma. Craniocaudal (C) and mediolateral oblique (D), double spot compression magnification views.

 

Any observations?

What BI-RADS® assessment category would you assign, and what is your recommendation?

Systematically review the images and actively look for potential lesions. In addition to splitting the craniocaudal (CC) and mediolateral oblique (MLO) views into thirds and evaluating the locations where cancers are likely to develop, look specifically for diffuse changes, masses, distortion, asymmetry, and calcifications. If you focus down with a magnification lens and look specifically for calcifications on every screening mammogram you review, you are unlikely to miss the relevant finding in this patient. Did you see the cluster of calcifications anteriorly at approximately the 6 o'clock position in the right breast? With what degree of confidence can you characterize these, and how definitive can you be with respect to their significance? Why not get more information in the form of double spot compression magnification views? There are other calcifications posteriorly (close to the edge of the film medially) in the lower inner quadrant on the right, but these contain lucent centers and are benign.

BI-RADS® category 0: need additional imaging evaluation.

 

What do you think?

What BI-RADS® assessment category would you assign, and what is your recommendation?

On the double spot compression magnification views, the morphology of the calcifications is much better demonstrated, as is the extent of the lesion. The calcifications in this cluster are pleomorphic, and there are linear forms. Armed with high-quality magnification views, our confidence in the likely diagnosis of ductal carcinoma in situ is increased significantly, and the need for a biopsy is easily justified.

BI-RADS® category 4: Suspicious abnormality; biopsy should be considered. A stereotactically guided needle biopsy is done on the same day as the magnification views. A high-nuclear-grade ductal carcinoma in situ with central necrosis is diagnosed on the core biopsy. A 1-cm area of high-nuclear-grade ductal carcinoma in situ with central necrosis and no associated invasion is described histologically on the lumpectomy specimen. No sentinel lymph node biopsy is done [pTis(DCIS), pNX, pMX; Stage 0].

Patient 9

Figure 2.12. Screening study, 73-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast. No prior films available for comparison. Craniocaudal (C) and mediolateral oblique (D) spot compression views, left breast. Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections, left breast. Craniocaudal (G) and mediolateral oblique (H) views. Box indicating location of potential mammographic abnormality.

 

Would you agree with a BI-RADS® assessment category 2: benign finding?

There is a mass in the left breast at approximately the 3 o'clock position, 4 cm from the left nipple. Did you see it (Fig. 2.12G, H)? What did you think? Good for you, if you are not willing to accept this as an intramammary lymph node. Although it may be that a fatty hilum and well-circumscribed margins are demonstrated with spot compression views, on these screening views no fatty hilum is apparent and the margins are not well defined. Remember: Make no assumptions. With what degree of certainty can you say this is a lymph node? If you are not sure, call the patient back for additional evaluation.

BI-RADS® category 0: need additional imaging evaluation.

 

What do you think now?

A 1-cm spiculated mass is confirmed on the spot compression views. A biopsy is indicated. An ultrasound is done to determine whether the lesion is identified on ultrasound; if it is, ultrasound guidance can be used for the core biopsy.

 

How would you describe the ultrasound findings?

A vertically oriented, irregular hypoechoic mass with indistinct and angular margins, shadowing, and associated distortion of the surrounding tissue is imaged at the 3 o'clock position, 4 cm from the left nipple, correlating to the expected location of the lesion seen mammographically. With the additional views and the ultrasound we can issue a succinct, definitive report on the finding, the likely significance, and our recommendations. Would you now agree with the assignment of BI-RADS® category 4: suspicious abnormality; biopsy should be considered.

An invasive ductal carcinoma is diagnosed following an ultrasound-guided core biopsy. A 0.7-cm invasive ductal carcinoma with tubular features (grade I) is diagnosed on the lumpectomy specimen. No metastatic disease is diagnosed in two excised sentinel lymph nodes [pT1b, pN0(sn)(i—), pMX; Stage I].

 

 

Patient 10

Figure 2.13. Screening study, 38-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Comparison study, craniocaudal (C) and mediolateral oblique (D) views.

 

 

RCC

RCC

LCC

LCC

RMLO

RMLO

LMLO

LMLO

Factor

(A)

(C)

(A)

(C)

(B)

(D)

(B)

(D)

kV

26

26

26

26

26

27

26

27

mAs

36

294

41

334

47

363

43

352

Comp(mm)

22

67

24

71

24

74

24

72

Target/filter

mo/mo

mo/rh

mo/mo

mo/rh

mo/mo

mo/rh

mo/mo

mo/rh

 

What do you think?

Are these mammograms from two different women?

If they are from the same woman, what is your working hypothesis?

Are there any significant findings in either mammogram?

These mammograms are normal and from the same woman, taken 20 months apart. In the interval, she lost 150 pounds. On the current study (Fig. 2.13A, B), breast size is decreased and parenchymal density is increased, with a concomitant decrease in fat compared with the study from 20 months before (Fig. 2.13C, D). The changes are bilateral and symmetric. There is no skin or trabecular thickening. The breasts are significantly thinner, as evidenced by the millimeters of compression used for exposure on the current study compared with 20 months before. Given similar kilovoltage peaks on both studies, the resulting milliamperage output is consistently lower on the current images. Also, note that rhodium kicked in for all of the films done on the comparison study.

Given the milliamperage output on the current study, what could the technologist have done to improve image quality?

Image contrast is partially related to the voltage used for exposure. As you increase voltage, you decrease image contrast. Optimally, you want to use a high enough voltage to penetrate the tissue adequately, but not much more than that. At a given voltage, the resulting amperage also needs to be considered, because this indirectly reflects the length of the exposure. As the amperage is increased, exposure time is increased, and as exposure time increases, motion blur may become an issue if the patient is unable to hold her breath. If, at a given voltage, the resulting amperage is high (>400 mAs) and the tissue is not adequately exposed, either voltage or compression (or both) need to be increased. As voltage is increased, the resulting amperage (and exposure time) decreases; as voltage is decreased, the resulting amperage (and exposure time) increases. In this woman, the resulting amperages on the current study are well below 400 mAs, so the voltage can be lowered without sacrificing adequate exposure of the tissue. As voltage is lowered, contrast is increased, improving overall image quality. Did you notice the low image contrast on the current images? Overall, the images (and particularly the fat) look gray, reflecting the poor contrast.

What is your differential for diffuse breast changes?

Differential considerations for diffuse changes that are usually unilateral, although rarely can be bilateral, include radiation therapy effect, inflammatory changes (e.g., mastitis), trauma, ipsilateral axillary adenopathy with lymphatic obstruction, dialysis shunt in the ipsilateral arm with fluid overload, invasive ductal carcinoma not otherwise specified, inflammatory carcinoma, invasive lobular carcinoma, or lymphoma. Invasive lobular carcinoma can lead to increases in breast density and size, or a decrease in breast size (the shrinking breast). Differential considerations for diffuse changes that are usually bilateral, although they can be unilateral, include hormone replacement therapy (e.g., estrogen), weight changes, congestive heart failure, renal failure with fluid overload, and superior vena cava syndrome. Additional rare benign causes include granulomatous mastitis, coumadin necrosis, arteritis, and autoimmune disorders (e.g., scleroderma). Obtaining a thorough history, examining the patient, and obtaining an ultrasound are often helpful in sorting through the differential considerations.

BI-RADS® category 1: negative. Next screening mammogram is recommended at age 40.

 

Patient 11

Figure 2.14. Screening study, 74-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)views with boxes on the medial and lower thirds of the breasts, respectively. Craniocaudal (E) and mediolateral oblique (F) spot compression views, left breast. Ultrasound image (G), antiradial (ARAD) projection, left breast. Ultrasound image (H), antiradial (ARAD) projection, left breast at the 9:30 o'clock position, 4 cm from the left nipple. A box delineates the mass.

 

What do you think?

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

In this patient, by splitting the images (Fig. 2.14C, D) in thirds and focusing your attention to the medial portions of the breasts on the craniocaudal (CC) views, a mass is detected medially in the left breast. On the mediolateral oblique (MLO) views, the corresponding mass is imaged in tissue projecting on the lower third of the left breast. If they are available, previous films will be helpful in assessing a change and should be requested before calling the patient back for a diagnostic evaluation. In the absence of comparison films, or if this represents a change when comparison is made to several sequential mammograms, additional evaluation is indicated.

BI-RADS® category 0: need additional imaging evaluation.

 

 

Where would you place the ultrasound transducer?

Be precise. (What clock position? How far back from the nipple?)

How would you describe the imaging findings?

Spot compression views confirm the presence of a 1-cm mass with indistinct margins. An irregular, hypoechoic mass with indistinct and spiculated margins and a partial echogenic halo is imaged on ultrasound (Fig. 2.14G, H). Although the lesion projects below the level of the nipple on the MLO view, be careful in assuming that this lesion is in the lower inner quadrant of the left breast. Some lesions that project below the level of the nipple on the mediolateral oblique (MLO) view are actually above the level of the nipple. In this patient, the lesion is in the lower aspect of the upper inner quadrant of the breast at the 9:30 o'clock position (see Fig. 2.6F-I), 4 cm from the left nipple.

BI-RADS® category 4: suspicious abnormality, biopsy should be considered. Rather than just consider it, a biopsy is done.

An invasive ductal carcinoma is diagnosed following the ultrasound-guided core biopsy. A grade II invasive ductal carcinoma measuring 1 cm is confirmed at the time of the lumpectomy, and the sentinel lymph node is negative for metastatic disease [pT1b, pN0(sn)(i—), pMX; Stage I].

 

Patient 12

Figure 2.15. Screening study, 87-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Screening images with a box indicating the location of the lesion on the left craniocaudal (C) and mediolateral oblique (D) views.

 

What do you think?

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

A mass is present in the upper cone of tissue on the mediolateral oblique (MLO) view. In many women, this area of tissue on the MLO is scalloped. If the tissue in this area rounds off asymmetrically, it should raise concerns about a developing lesion. A spiculated mass is seen laterally in the left craniocaudal view.

BI-RADS® category 0: need additional imaging evaluation.

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

Spot compression views (not shown) confirm the presence of a 1.5-cm spiculated mass at this site. A biopsy is indicated. Ultrasound-guided core biopsy is done at the time of the diagnostic study. An invasive mammary carcinoma is reported histologically. A 1.6-cm grade I invasive ductal carcinoma with associated low-nuclear-grade ductal carcinoma with central necrosis is reported on the lumpectomy specimen. No metastatic disease is diagnosed in two excised sentinel lymph nodes [pT1c, pN0(sn)(i—), pMX; Stage I].

 

Patient 13

Figure 2.16. Screening study, 68-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

 

What do you think?

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

Arterial calcifications are present bilaterally. The artery, coursing inferiorly at the anterior edge of the right pectoral muscle on the mediolateral oblique (MLO) view, is the lateral thoracic artery. It is always seen coursing in the subcutaneous tissue laterally on the craniocaudal (CC) view. The calcified artery, entering the breast just inferior to the left pectoral muscle on the MLO view and extending toward the nipple, is likely a perforating branch of the internal mammary artery. On the CC views, these are more commonly medial in location but can also be seen laterally. Additionally, large rodlike calcifications, oriented toward the nipple, are noted scattered bilaterally, and a lymph node with a prominent fatty hilum is seen at the edge of the left pectoral muscle superiorly on the left MLO. Following a systematic review of the films, no significant finding is perceived. No additional views are indicated.

BI-RADS® category 1: negative. Annual screening mammography is recommended (or BI-RADS® category 2: benign finding can be used if you describe the arterial or secretory calcifications in your report).

 

Patient 14

Figure 2.17. Screening study, 55-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Mediolateral oblique (C) views, 2 years prior to (B). Right craniocaudal and left craniocaudal exaggerated laterally views (D) and spot compression view, mediolateral oblique (E) projection. Ultrasound images in longitudinal (LON) (F) and transverse (TRS) (G) projections of a mass at the 2 o'clock position, 5 cm from the left nipple. Ultrasound image (H)in transverse (TRS) projection of a mass at the 2 o'clock position, 5 cm from the left nipple. With the patient in the supine position the mass is closely apposed to the deep pectoral fascia (arrowheads). As the patient is imaged and the mass is compressed, mass effect is noted on the deep pectoral fascia.

 

What do you think?

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

Review the images systematically. Focus your attention on smaller amounts of tissue by splitting the craniocaudal (CC) and mediolateral (MLO) views into thirds (Figs. 2.1 and 2.2). Look for specific findings, including diffuse changes, masses, distortion, asymmetry, and calcifications. Review areas on the mammograms where breast cancers are likely to develop, specifically, the fatty stripe of tissue between pectoral muscle and glandular tissue on MLO views, the superior cone of tissue on MLO views, medial tissue on CC views, fat-glandular interfaces, and subareolar areas (Fig. 2.3). Focus down with a magnification lens, particularly when looking for small masses, distortion, and clusters of calcifications.

Is there a potential mass in this patient?

Did you notice the possible mass in the fatty stripe of tissue between pectoral muscle and glandular tissue on the left MLO? No definite abnormality is identified on the CC view, but it may be partially imaged at the edge of the film in the far posterolateral aspect of the left breast. With what degree of confidence can you characterize this potential finding, and how definitive can you be about what the next step should be? How about prior films? If prior films are not available, or this represents an interval change, additional imaging may be helpful in determining the significance of this finding.

 

The potential abnormality perceived on the current study is not seen on the prior film. Additional evaluation is indicated.

BI-RADS® category 0: need additional imaging evaluation.

What additional views will you request?

Be specific

 

How would you describe the imaging findings?

What is your recommendation?

A 1-cm mass is confirmed laterally on the exaggerated craniocaudal views laterally (XCCL). The margins of the mass are indistinct and partially obscured on the mediolateral oblique (MLO) spot compression view. On ultrasound, a vertically oriented, irregular mass with indistinct, spiculated margins and an echogenic rim is imaged, corresponding to the area of mammographic concern. Associated disruption of Cooper ligaments is noted. With the patient supine, this mass is directly on the pectoral fascia and muscle. A developing solid mass with the described imaging features on a post- or perimenopausal woman requires biopsy.

BI-RADS® category 4: suspicious abnormality; biopsy should be considered. Rather than just consider it, a biopsy is done.

An invasive mammary carcinoma is reported on the ultrasound-guided core biopsy. A 0.9-cm, grade II invasive mammary carcinoma, apocrine type with associated intermediate-grade ductal carcinoma in situ, is diagnosed on the lumpectomy specimen. No metastatic disease is diagnosed in three excised sentinel lymph nodes [pT1b, pN0(sn)(i—), pMX; Stage I].

Apocrine carcinomas represent less than 1% of all breast cancers and usually present as a mass that is detected mammographically or clinically. The lesions are characterized by the presence of apocrine cells. Some of these cells are characterized by the presence of an eosinophilic granular cytoplasm, often localized to the apical portion of cells, and cells with foamy cytoplasm filled with small vacuoles. The presence of gross cystic disease fluid protein, GCDFP-15, characterizes both benign and malignant apocrine differentiation.

 

Patient 15

Figure 2.18. Screening study, 54-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)views with boxes on the medial and upper thirds of the breasts respectively. Craniocaudal (E) and mediolateral oblique (F) spot compression views, right breast.

 

What do you think?

Is this mammogram normal, possibly abnormal or definitely abnormal?

Review the images systematically. Do you see a potential mass? Split the craniocaudal (CC) and mediolateral (MLO) views into thirds and go back and forth between the right and left breasts (Fig. 2.18C, D). Does something catch your eye medially and superiorly in the CC and MLO views of the right breast, respectively? Although this is of concern, and it is in a comparable location on the two projections, it appears more spread out and less dense on the CC view (Fig. 2D). With what degree of certainty can you say this is normal or abnormal? How would you dictate the report? Prior films may be helpful. If these are not available, or this represents a change, why commit yourself when you can obtain spot compression views and, if needed, correlative physical examination and sonography? Depending on the workup, a biopsy may be indicated.

BI-RADS® category 0: need additional imaging evaluation.

 

 

What do you think now?

Puff goes the magic dragon! Normal glandular tissue is imaged when focal spot compression is applied in the areas of initial concern. Although the additional mammographic images are definitive, correlative physical examination and sonography can be done in the medial quadrants of the right breast for added reassurance.

BI-RADS® category 1: negative. Annual screening mammography is recommended.

Patient 16

Figure 2.19. Initial screening study, 38-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D) double spot compression magnification views, right breast.

 

Any observations?

What BI-RADS® assessment category would you assign?

Review the images systematically, looking actively for potential lesions. In addition to splitting the craniocaudal (CC) and mediolateral oblique (MLO) views into thirds and evaluating the locations where cancers often develop, look specifically for diffuse changes, masses, distortion, asymmetry, and calcifications. If you focus down with a magnification lens and look specifically for calcifications on every screening mammogram you review, you are unlikely to miss the relevant finding in this patient. Did you see the cluster of calcifications in the right subareolar area? Although the appearance of the calcifications is of concern, with what degree of confidence can you characterize these and their extent? Why not get more information in the form of double spot compression magnification views? If needed, and the patient consents, a biopsy can be done at the time of the magnification views.

BI-RADS® category 0: need additional imaging evaluation.

 

How would you describe the imaging findings?

On the double spot compression magnification views, the morphology of the calcifications is much better demonstrated, as is the extent of the lesion. The calcifications in this cluster are pleomorphic and variable in density. In addition to some of the calcifications demonstrating linear orientation, others are linear. The borders of some of the linear calcifications are irregular and there are associated clefts. This is likely to represent ductal carcinoma in situ with central necrosis. There is an associated density such that gross or microscopic invasive ductal carcinoma may be present. Armed with high-quality magnification views, our confidence in the diagnosis and the appropriate recommendation is greatly enhanced. A succinct, definitive report can be generated.

BI-RADS® category 5: Highly suggestive of malignancy; appropriate action should be taken. Appropriate action, in the form of an imaging guided biopsy, is undertaken following completion of the magnification views.

A high-nuclear-grade ductal carcinoma in situ with central necrosis is diagnosed on the core samples. This diagnosis is confirmed at the time of the lumpectomy, and no invasion is identified. No sentinel lymph node biopsy is done [pTis(DCIS), pNX, pMX; Stage 0].

 

Patient 17

Figure 2.20. Screening study, 45-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

What is the primary observation?

A focal area of parenchymal asymmetry is present in the upper outer quadrant of the left breast. It is of comparable size and density and in the same approximate distance from the nipple on the two projections, but there is fat interspersed in the glandular tissue. In most patients, focal parenchymal asymmetry is a normal variant. Progressive development of focal parenchymal asymmetry can be benign, presumably related to hormonal variations.

What additional information would you like?

A good history is important. Has the patient had any breast surgery (e.g., a comparable area of tissue excised from the right breast, or does this finding reflect fat necrosis postsurgery)? Is there any history of trauma to this site (e.g., hematoma)? Estrogen use? Presumably, if the patient had any focal tenderness, erythema, skin dimpling, or discoloration limited to this site, she would have been scheduled for a diagnostic evaluation or your technologist would have indicated this on the woman's history sheet.

Comparison with prior studies is critical. If the area of focal parenchymal asymmetry represents a change, or if no prior studies are available for comparison, spot compression views and ultrasound with correlative physical examination are recommended to exclude an underlying malignancy. If normal tissue is imaged on spot compression views and ultrasound, and there is no corresponding palpable abnormality on physical examination, no further intervention is recommended. Magnetic resonance imaging may also provide helpful information, particularly in high-risk patients. If concerns remain following the diagnostic evaluation, an imaging-guided biopsy can be undertaken. Fibrosis or pseudoangiomatous stromal hyperplasia (PASH) is often the diagnosis on core biopsies done through these areas.

What is your differential at this point?

Differential considerations include normal variant, hormone replacement therapy effect, asymmetry secondary to prior surgical excision of the corresponding tissue in the right breast, focal fibrosis, pseudoangiomatous stromal hyperplasia (PASH), posttraumatic changes (evolving hematoma; fat necrosis), mastitis, fibroadenolipoma (hamartoma), invasive ductal carcinoma not otherwise specified, invasive lobular carcinoma, and lymphoma.

In this patient, the area is unchanged from prior studies (not shown).

This mammogram can be categorized as BI-RADS® category 1: negative. BI-RADS® category 2: benign finding is used if the observation is described in the report. Annual screening mammography is recommended.

 

Patient 18

Figure 2.21. Screening study, 65-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)spot compression views, right subareolar area. Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections, right subareolar area.

 

What do you think?

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

Review the images systematically. Look for specific findings, including diffuse changes, masses, distortion, asymmetry, and calcifications. Focus your attention on smaller amounts of tissue by splitting the craniocaudal (CC) and mediolateral oblique (MLO) views into thirds (Figs. 2.1 and 2.2). Review those areas where breast cancers commonly develop, specifically the fatty stripe of tissue between pectoral muscle and glandular tissue on MLO views, the superior cone of tissue on MLO views, medial tissue on CC views, the fat-glandular interfaces, and the subareolar areas (Fig. 2.3). Focus down with a magnification lens, particularly when looking for small masses, distortion, and clusters of calcifications. Is there a potential mass in this patient? Did you notice the right subareolar area? With what degree of confidence can you characterize this potential finding, and how definitive can you be in determining its significance? Prior films will be helpful, as will a surgical history. If prior films are not available (and the patient has no history of surgery), additional imaging is needed to determine the significance of this finding.

BI-RADS® category 0: need additional imaging evaluation.

 

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

Spot compression views of the right subareolar area confirm the presence of a 2-cm mass. The patient has no history of previous breast surgery. An irregular, vertically oriented, hypoechoic mass with spiculated and angular margins and associated shadowing is imaged in the right subareolar area on ultrasound. These findings, in a 65-year-old woman with no history of surgery at this site, require biopsy. The additional views are helpful in establishing the presence of a lesion and demonstrating the morphologic features of the lesion.

BI-RADS® category 4: Suspicious abnormality; biopsy should be considered.

Rather than just consider it, a biopsy is done. An invasive lobular carcinoma is diagnosed, following ultrasound-guided core biopsies. A 2.2-cm invasive lobular carcinoma is confirmed at the time of the lumpectomy. Lymphovascular space involvement is present and metastatic disease is found in the sentinel lymph node, so an axillary dissection is undertaken. Three of 12 lymph nodes have metastatic disease with extracapsular extension in one of the three positive lymph nodes (pT2, pN1a, pMX; Stage IIB).

What is the significance of lymphovascular space involvement?

Lymphovascular space involvement is described in approximately 15% of patients with invasive ductal carcinoma. It has been described as an unfavorable prognostic finding, particularly in node-negative patients treated with either mastectomy or lumpectomy. The significance in patients with positive axillary lymph nodes (as in our current patient) is not clear. Extracapsular extension has also been described as an unfavorable prognostic factor.

What is the single most important prognostic factor in women with an invasive breast cancer diagnosis?

The presence of metastatic disease in axillary lymph nodes is the single most important prognostic factor, and there is a direct correlation between the number of positive lymph nodes and disease-free survival, as well as mortality. In patients with tumors <2 cm in size, Carter et al. reported overall 5-year survival rates of 96.3% in patients with negative lymph nodes, 87.4% for patients with one to three positive axillary lymph nodes, and 66% for patients with four or more positive axillary lymph nodes. In the sixth edition of the American Joint Committee on Cancer (AJCC) Staging Manual, the pathologic status of node-positive patients has been revised to reflect the prognostic significance of the number of positive lymph nodes: pN1a for patients with one to three positive axillary lymph nodes; pN2a for patients with four to nine positive axillary lymph nodes, and pN3a for patients with 10 or more positive axillary lymph nodes.

 

Patient 19

Figure 2.22. Screening study, 40-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)spot compression views, left breast. Additional views to address described technical limitations are not shown. Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections, upper outer quadrant, left breast.

 

What do you think?

Would you agree with a BI-RADS® assessment category 1 or 2 for this mammogram?

Did you review this study for technical adequacy as your starting point? Positioning and compression are not optimal. There is insufficient pectoral muscle on the mediolateral oblique (MLO) views. Although it is thick in the axillary region, pectoral muscle should be seen to the level of the nipple and it should have a convex anterior margin. Given the triangular shape of the muscle in this patient, several things went wrong during positioning. It is likely that an incorrect angle of obliquity was selected, the muscles were not relaxed, and the breasts were not adequately mobilized medially (or if they were, the patient pulled out during positioning).

On the craniocaudal (CC) views, a significant amount of posterior tissue is excluded from the images. In determining whether an adequate amount of tissue has been included on the CC views, look for pectoral muscle posteriorly or for cleavage medially. If neither of these is seen, measure the posterior nipple line (PNL) on the MLO (and remember, in this patient, positioning on the MLO views is not optimal, so the PNL measurement is not an optimal measure of the amount of tissue this patient has) and compare it to that measured on the CC views (Fig. 2.4E, F). The PNL measurement on the CC view should be within 1 cm of that measured on the MLO view. It is not in this patient. Also, notice the relationship of the mass to the edge of the film on the MLO view and compare it to that seen on the CC view.

There is inadequate separation of tissue, particularly on the MLO views, consistent with suboptimal compression. Additionally, if you evaluate the left MLO and specifically send your eyes looking for motion, you will notice blurring of tissue anteriorly; an additional sign of suboptimal compression. Blurring can tomogram small spiculated masses and clusters of calcification off the image; however, it often goes undetected because we do not specifically assess and insist on high image quality. As with subtle findings of breast cancer, blurring will go undetected unless you recognize how much it can limit your ability to perceive important lesions and you focus your attention on looking for it before attempting to look for potential lesions.

Did you notice anything else, and what would you like to do next?

How about the mass in the lateral aspect of the left breast? On the MLO view, it is likely to be on the upper cone of tissue. As a further indication of how much tissue is missing on the CC view, notice the relationship of this lesion to the edge of the film on the CC and the MLO view. Momentarily you might think that what you see on the CC view is not what you see on the MLO view; however, if you measure back from the nipple, the lesion is at approximately the same distance from the nipple. Based on the technical limitations of the study alone, the patient needs to be called back. With respect to the mass noted in the left breast, comparison studies may be helpful. If the mass is decreasing in size, or has been previously evaluated, it may not require additional evaluation at this time. If there are no prior studies, or these are unavailable, or if this represents an interval change, additional evaluation is indicated.

BI-RADS® category 0: need additional imaging evaluation.

 

What do you think now?

In a 40-year-old woman, what differential would you consider based on the mammographic findings alone?

A 1-cm mass with indistinct margins is confirmed on the spot compression views. At this point, in a 40-year-old woman, benign differential considerations are extensive and include an intramammary lymph node, cyst, fibroadenoma (complex fibroadenoma, tubular adenoma), papilloma, focal fibrosis, pseudoangiomatous stromal hyperplasia (PASH), sclerosing adenosis, phyllodes tumor, or a granular cell tumor. In the malignant category, one would consider an invasive ductal carcinoma not otherwise specified, medullary carcinoma, although possible mucinous and papillary carcinomas are usually diagnosed in postmenopausal women, a metastatic lesion (in patients with a known malignancy), and adenoid cystic carcinoma. Invasive lobular carcinomas do not typically present as a round-oval mass.

 

How would you describe the ultrasound finding?

What is your recommendation?

An irregular, vertically oriented, hypoechoic mass with angular and spiculated margins is imaged at the 2 o'clock position, 6 cm from the left nipple. Given the indistinct margins mammographically, and the sonographic appearance of this lesion, a biopsy is indicated.

BI-RADS® category 4: Suspicious abnormality; biopsy should be considered.

A biopsy is done. An invasive ductal carcinoma is diagnosed, following an ultrasound-guided core biopsy. A 0.8-cm grade III invasive ductal carcinoma is diagnosed following the lumpectomy, and two excised sentinel lymph nodes are negative for metastatic disease [pT1b, pN0(sn)(i—), pMX; Stage I].

 

Patient 20

Figure 2.23. Screening study, 58-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)double spot compression magnification views, left breast. Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections in the upper inner quadrant of the left breast. T1-weighted, sagittal image (H) left breast, precontrast. T1-weighted, sagittal image (I), left breast, same tabletop position as shown in (H), 1 minute following contrast administration. T1-weighted, sagittal image (J), left breast, same tabletop position as shown in (H), 2 minutes following contrast administration. T1-weighted, sagittal image (K), left breast, same tabletop position as shown in (H), 10 minutes following contrast administration. Magnetic resonance image in radial (RAD) projection (G) demonstrating the calcification seen mammographically in the mass. Specimen radiograph (L), 3× magnification obtained on a dedicated specimen radiography unit.

What do you think, and what BI-RADS® assessment category would you assign?

A round mass with an adjacent area of calcifications is identified in the left breast. Although a malignancy is suspected, additional evaluation is beneficial in better characterizing the extent of the lesion and the morphology of the calcifications.

BI-RADS® category 0: need additional imaging evaluation.

 

How would you describe the findings?

Double spot compression views demonstrate a 1-cm round mass with microlobulated, indistinct and spiculated margins. Predominantly round calcifications demonstrating a linear (branching) orientation extend for approximately 3 cm anterior to the mass.

 

How would you describe the findings?

On ultrasound, a round mass with indistinct margins, an echogenic halo, minimal posterior enhancement, and disruption of Cooper ligaments is imaged at the 10 o'clock position, 8 cm from the left nipple. Did you notice the calcification in the mass mammographically and on ultrasound? The calcification noted in the mass mammographically on both projections is also identified on the ultrasound (Fig. 2.23G). However, the linearly oriented calcifications cannot be identified with certainty on ultrasound.

Based on the imaging finding, what is your diagnosis (don't just say “cancer”; be specific)?

The mass, in conjunction with the calcifications, is almost pathognomonic for an invasive ductal carcinoma (mass) with an associated ductal carcinoma in situ (calcifications). An invasive mammary carcinoma is diagnosed following an ultrasound-guided core biopsy of the mass. As is our routine on patients with a breast cancer diagnosis following an imaging-guided biopsy, magnetic resonance imaging is obtained. This further assesses the ipsilateral breast for unsuspected multifocal or multicentric disease, as well as the status of the contralateral breast.

 

How would you describe the findings?

The dynamic sequence demonstrates a mass with rapid wash-in and wash-out of contrast, characteristic of malignant lesions. Morphologically, this is an irregular mass with irregular margins and heterogeneous enhancement. Ductal enhancement is present, corresponding to the area of calcifications seen mammographically. No additional lesions are noted in the left breast, and no masses or other abnormal areas of enhancement are seen in the right breast (images not shown).

At the time of the preoperative wire localization, the lesion is bracketed with two wires to assure complete excision of the lesion (i.e., the mass and all calcifications). One of the wires is used to skewer the mass and a second is placed anteriorly through the leading edge of the calcifications. The excised tissue is placed in a plastic container (a Dubin device) and an alphanumeric grid is used to compress the tissue. A radiograph of the specimen is taken to assure excision of the localized lesion(s). In this patient, the mass is seen at the edge of the image (Fig. 2.23L, arrowhead) and the calcifications extending away from the mass are also present. The apparent proximity of the mass to one of the margins on the radiograph is discussed with the surgeon so that additional tissue may be taken.

The Dubin device provides an alphanumeric grid (letters partially seen) with corresponding “holes” so that pins can be placed through the specimen to mark the location of the lesion(s) for the pathologist. Portions of the localizing wires are seen on the radiograph (arrows). Also noted is one of several markers placed by the surgeon intraoperatively to indicate the different margins, thereby orienting the specimen for the pathologist. The marker seen here is the skin marker; additional markers include caudal, cranial, medial, and lateral markers. In addition to these markers used by the surgeon, the pathologist inks the margins so that extension of tumor to the margins can be assessed at the time of histologic evaluation. If tumor is seen extending to the margins, re-excision is usually indicated.

A 1.2-cm invasive mammary carcinoma with apocrine features is reported histologically. Associated high-nuclear-grade ductal carcinoma in situ with central necrosis is present. The sentinel lymph node is normal [pT1c, pN0(sn)(i—), pMX; Stage I].

 

Patient 21

Figure 2.24. Screening study, 44-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

What observations can you make on this patient's mammogram, and what conclusion can you draw?

What recommendation would you make?

Pertinent observations include fibrotic bands in the subareolar areas on the craniocaudal views, islands of nonanatomically distributed tissue bilaterally, inferior displacement of tissue with a swirling pattern on the right mediolateral oblique (MLO) view, and skin thickening inferiorly on the left MLO. These findings are common in women following reduction mammoplasty. From a review of her history form, she has had a reduction mammoplasty. No masses or malignant type calcifications are present.

BI-RADS® category 1: negative. Annual screening mammography is recommended.

Patient 22

Figure 2.25. Screening study, 82-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)views, 3 years before those shown above. Ultrasound image (E) of the left breast at the 9 o'clock position.

 

What do you think and what would you like to do next?

In reviewing this mammogram, did you consider the possibility of a diffuse abnormality? Remember to initially sit back and look at the study from a distance.Assess technical adequacy and the possible presence of diffuse changes. The trabecular markings are increased diffusely, thickened, and extend close to the chest wall. For diffuse changes to be appreciated, particularly when they are bilateral, you need to consider them specifically as a possibility; otherwise they may go undetected.

 

What do you think a comparison of technical factors would show?

In addition to the comparison studies, what else might help you with the differential?

The initial perception of a diffuse abnormality can be confirmed by comparing present to prior mammograms (Fig. 2.25C, D). In comparing the two studies, consider the overall density of the breast parenchyma and the prominence of the trabecular pattern. As you would expect, peak kilovoltages and milliamperage output are higher and the breasts are less compressible on the current study compared with the study from 3 years earlier. Reviewing the patient's history form should be helpful as you consider the differential: The patient is short of breath (as detailed by the technologist), is on diuretics, and has a history of congestive heart failure (CHF). In this patient, the described findings are related to CHF and, as the CHF is treated, you can expect significant improvements in the mammographic findings.

Although an ultrasound is not indicated in this patient, you can expect to see skin thickening, increased echogenicity of the tissue, and reticulation consistent with edema.

What is your differential for diffuse breast changes?

Differential considerations for diffuse changes that are usually unilateral, although rarely can be bilateral, include radiation therapy effect, inflammatory changes (e.g., mastitis), trauma, ipsilateral axillary adenopathy with lymphatic obstruction, dialysis shunt in the ipsilateral arm with fluid overload, invasive ductal carcinoma not otherwise specified, inflammatory carcinoma, invasive lobular carcinoma, or lymphoma. Invasive lobular carcinoma can lead to increases in breast density and size, or a decrease in breast size (the shrinking breast). Differential considerations for diffuse changes that are usually bilateral, although they can be unilateral, include hormone replacement therapy (e.g., estrogen), weight changes, congestive heart failure, renal failure with fluid overload, and superior vena cava syndrome. Additional rare benign causes include granulomatous mastitis, coumadin necrosis, arteritis, and autoimmune disorders (e.g., scleroderma). Obtaining a thorough history, examining the patient, and obtaining an ultrasound are often helpful in sorting through the differential considerations.

BI-RADS® category 2: benign finding. Annual screening mammography is recommended.

 

Patient 23

Figure 2.26. Screening study, 77-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

What do you think, and would you like to do anything else?

There are scattered densities in an otherwise predominantly fatty pattern. Is it possible that any one of these densities represents an early malignancy? This is what makes what we do a challenge, particularly because it would not be ideal to call back all women with this mammographic appearance. Comparison with prior studies dating back several years is indicated in women with this type of parenchymal pattern. If any of these areas represents a change, additional evaluation is indicated; however, if the findings are stable, annual mammography is recommended. Arterial calcifications, noted bilaterally, are most likely perforating branches from the internal mammary artery. There are also large rodlike calcifications present bilaterally; these are benign and require no additional evaluation. Lymph nodes are seen projecting superimposed on the left pectoral muscle.

Did you notice the uneven exposure on the craniocaudal views posteromedially (more prominent on the right)?

What does this reflect?

This usually reflects suboptimal compression with an associated air pocket. Consequently, evaluate the tissue in these areas carefully for blur, because the compression of the tissue in these areas is probably not optimal.

BI-RADS® category 2: benign finding. Annual screening mammography is recommended.

 

Patient 24

What do you think?

Is the tissue too dense for a 59-year-old woman?

What is your working hypothesis, and what would you like to do next?

How about prior films for comparison?

Figure 2.27. Screening study, 59-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Mediolateral oblique (C) views, 1 year prior to (B), and mediolateral oblique (D) views, 6 years prior to those of (B). Mediolateral oblique (E) views. Micromark clip (arrow) is seen in the left breast consistent with a prior stereotactically guided, vacuum-assisted biopsy for microcalcifications. The potential perceived lesion is within the box. Diagram (F) illustrating a triangulation method described by Sickles to localize lesions on orthogonal views. Ninety-degree lateral, mediolateral oblique, and craniocaudal views are lined up using the nipple as the reference point. A line is then drawn connecting the lesion on the two views in which it is seen. The line is extended into the third image. The lesion can be expected along the course of this line. By measuring back from the nipple, you can approximate the location of the lesion along the course of the line. Ultrasound image (G) in the radial (RAD) projection of the lesion identified posteriorly (Z3) at the 11 o'clock position of the left breast.

 

 

What do you think now?

When screening studies are hung on the multiviewer, what is the routine for which comparison films to hang?

A micromark clip is present in the upper outer quadrant of the left breast, consistent with the history of a prior stereotactially guided biopsy (Fig. 2.27E). Arterial calcifications are noted bilaterally, as are several benign-appearing lymph nodes superimposed on the pectoral muscles. However, with careful evaluation, the mass superimposed on the lower aspect of the left pectoral muscle does not have an identifiable fatty hilum (Fig. 2.27E). When compared with prior studies, this mass has increased in size and the change in size is best appreciated when comparison is made to the earliest study available (Fig. 2.27D). Subtle changes are more difficult to appreciate from one year to the next, but may be readily apparent when an earlier study is used. Consequently, when the screening board is hung, we use the study from 2 years previous to the current study. If the patient has other studies, these are also immediately available in the patient's jacket for our review. It is common for us to review several prior studies, including the earliest study available in the patient's jacket, particularly before calling a patient back.

On the craniocaudal (CC) view, where would you expect to find this lesion and what views do you want your technologist to do to image this lesion in the CC projection?

Obviously, this will depend on the location of the lesion; however, this is not known because the lesion is not seen on the CC view. Did you assume this lesion is in the lateral aspect of the left breast? Remember: make no assumptions. When you make assumptions, you pigeonhole yourself. Logically, how can we establish if this lesion is medial, central, or lateral in location? A 90-degree lateral view can help us determine the location of this lesion. If the lesion moves up in going from mediolateral oblique (MLO) to lateral view, the lesion is in the medial aspect of the breast. If the lesion moves down in going from MLO to lateral view, the lesion is in the lateral aspect of the breast; and if the lesion does not shift in position, it is central in location. Alternatively, line up lateral, MLO, and CC views with the nipple on the same horizontal plane for the three views and draw a line connecting the lesion on the lateral and MLO views and extend it into the CC view. On the CC view, the lesion can be found somewhere along the course of the resulting line. You can localize the lesion more precisely by measuring how far posteriorly the lesion is in the breast with respect to the nipple (Fig. 2.27F).

As you can see from the ultrasound (Fig. 2.27G), this lesion is in the upper, inner quadrant of the left breast at the 11 o'clock position, posteriorly (Z3) sitting on the pectoral muscle. An oval, nearly isoechoic mass with parallel orientation, indistinct margins, and some shadowing as well as straightening and thickening of Cooper ligaments is imaged on ultrasound.

BI-RADS® category 4: suspicious abnormality; biopsy should be considered.

An invasive ductal carcinoma is diagnosed following the ultrasound-guided core biopsy. A 1.2-cm tubular carcinoma is diagnosed on the lumpectomy specimen. No metastatic disease is diagnosed in four excised sentinel lymph nodes [pT1c, pN0(sn)(i—), pMX; Stage I]. The well-differentiated nature of this lesion could have been suggested based on the relatively slow growth of the mass compared with 1 and 6 years previously.

 

 

Patient 25

Figure 2.28. Screening study, 55-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

What are the pertinent observations?

There is global parenchymal asymmetry in the left breast. Establishing the presence of global parenchymal asymmetry requires comparison with the contralateral side. A greater volume of tissue is present in the left breast compared to the same area in the right breast. As defined in the Fourth Edition of BI-RADS®, global asymmetry should involve at least one quadrant of the breast. Although breast tissue is more commonly symmetric, global asymmetry, as demonstrated here, can be seen in a small number of woman as a normal variant. No mass or distortion is noted in the area of increased tissue on the right. The tissue in this area is scalloped and contains associated areas of fatty lobulation. Abnormal, asymmetric changes may be the result of chest wall trauma (e.g., burns), congenital abnormalities (e.g., Poland syndrome), or surgery when the corresponding area of tissue in the contralateral breast has been excised. Invasive ductal carcinomas can present with global areas of parenchymal asymmetry, but these are usually clinically apparent and readily palpable. Invasive lobular carcinoma can also present with global areas of parenchymal asymmetry and progressive changes in breast size (either increases or decreases); palpable findings may be present, but they are often more subtle in patients with invasive lobular carcinomas. Rarely, lymphoma can present with diffuse, asymmetric involvement of one breast.

Based on your observations, what is your working hypothesis for this patient and what BI-RADS® category would you use?

In this woman, you can establish the iatrogenic cause of the asymmetry by making all pertinent observations. Did you notice the radio-opaque linear marker used on the right craniocaudal view at the site of a prior excisional biopsy? Did you notice that the right breast is slightly smaller than the left? The patient has had a prior biopsy in the upper outer quadrant of the right breast with resulting asymmetry of the remaining tissue on the left. Did you notice the suboptimal positioning on the mediolateral oblique views? An inadequate amount of pectoral muscle is included in the images.

How often do you see mammographic changes following an excisional biopsy?

And what are the possible changes?

We do not routinely use scar markers on screening studies because no perceivable abnormality is apparent in more than 50% of women following a breast biopsy. Additionally, in those women in whom postoperative changes are noted, they can usually be characterized as such without the use of scar markers. Placing markers on the breast is time-consuming, can be distracting at the time of interpretation, and is relatively costly. Changes that can be seen following an excisional biopsy include a decrease in the size of the affected breast, localized skin thickening and retraction, architectural distortion, a spiculated or mixed-density mass, oil cyst(s), dystrophic calcifications, and areas of focal or global parenchymal asymmetry in the contralateral breast, as demonstrated with this patient's mammogram.

BI-RADS® category 1: negative, unless this is the first study following the biopsy, in which case BI-RADS® category 2: benign finding, can be used if the observation is described in the report. Annual screening mammography is recommended.

 

Patient 26

Figure 2.29. Screening study, 54-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)focusing on the mid aspect of the breasts. Craniocaudal (E) and mediolateral oblique (F) spot compression views. Ultrasound images in radial (RAD) (G)and antiradial (ARAD) (H) projections, left breast at the 2 o'clock position, anteriorly (Z1).

 

What do you think?

Do you see a potential lesion?

Review the images systematically. Do you see a potential mass? Split the craniocaudal and mediolateral oblique views into thirds to focus your attention as you go back and forth between the right and left breasts. Does something catch your eye in the left breast anterolaterally? With what degree of certainty can you say this is normal or abnormal? How would you dictate the report? Why not get additional information by comparing the current study with prior films, and depending on what the comparison shows, obtaining spot compression views, correlative physical examination, and sonography? Depending on what is found on the workup, a biopsy may be indicated.

BI-RADS® category 0: need additional imaging evaluation.

What is the goal when viewing and interpreting screening mammograms, and why place a high emphasis on additional imaging evaluations?

On screening studies our goal is to detect potential abnormalities. We make no effort to characterize potential or true lesions on screening studies. Additional evaluations increase our confidence in appropriate recommendations and often point to the proper diagnosis. They also provide us with the opportunity to establish a rapport with our patients and complete workups, including imaging guided biopsies, when indicated. Definitive and directive reports are generated. Consequently, the only BI-RADS® assessment categories we use on our screening studies are category 1: negative, category 2: benign finding(s), and category 0: need additional imaging evaluation or need prior mammograms for comparison.

 

Do you see a possible mass in the left subareolar area?

 

Do the spot compression views help you?

With what degree of certainty can you now say there is a significant abnormality in the left breast?

A 2-cm, irregular, spiculated mass is confirmed on the spot compression views. The ultrasound demonstrates a hypoechoic, intensely shadowing mass with vertical (i.e., not parallel or taller than wide) orientation and spiculation. If there is no history of surgery, significant trauma, or mastitis at this site, this finding requires a biopsy, which can be readily, easily, and safely undertaken at the time of the diagnostic evaluation using ultrasound guidance. The information provided by the additional views is critical in enabling us to make recommendations confidently and to dictate a succinct, definitive, and directive report (in essence, a 2-cm, spiculated, irregular mass is confirmed at the 2 o'clock position of the left breast 1 cm from the nipple. Biopsy is indicated. An imaging-guided biopsy is undertaken and reported separately).

BI-RADS® category 4: suspicious finding; biopsy is indicated. An ultrasound-guided core biopsy is done at the time of the diagnostic evaluation. An invasive mammary carcinoma, thought to be either an invasive ductal carcinoma with lobular features or an invasive lobular carcinoma, is reported on the core samples. A 2.3-cm invasive lobular carcinoma is reported histologically following the lumpectomy. The sentinel lymph node is normal [pT2, pN0(sn)(i—), pMX; Stage IIA].

 

Patient 27

Figure 2.30. Screening study, 62-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, right breast. Craniocaudal (C) and mediolateral oblique (D) views, right breast. The potential lesion is enclosed in the box. Spot compression view (E), right craniocaudal projection. Ultrasound images in longitudinal (LON) (F) and transverse (TRS) (G) orientations, right breast.

Any observations?

Do you think additional views are indicated?

In reviewing this mammogram, consider the fat-glandular interfaces and medial tissue. Straight lines can be seen radiating out from an area of density in the upper inner quadrant of the right breast. If there is no history of surgery at this site, additional evaluation is indicated.

BI-RADS® category 0: need additional imaging evaluation.

 

 

What do you think now?

A spiculated mass is confirmed with the spot compression view. Based on the mammographic findings, a biopsy is indicated.

 

How would you describe the ultrasound findings?

A 1.5-cm irregular mass with indistinct and angular margins, shadowing, and associated disruption of the normal tissue planes (distortion) is imaged at 1 o'clock, 8 cm from the right nipple, corresponding to the area of mammographic concern.

BI-RADS® category 4: suspicious abnormality; biopsy should be considered. An invasive ductal carcinoma is reported histologically following an ultrasound-guided biopsy. A 2-cm grade I, invasive ductal carcinoma is reported on the lumpectomy specimen. Metastatic disease is diagnosed in one of five excised axillary lymph nodes (pT1c, pN1, pMX; Stage IIA).

What is the reported incidence of axillary nodal metastasis in patients with T1 tumors, and what factors have been suggested as predictors for nodal involvement?

The reported incidence of axillary nodal metastasis in patients with T1 tumors (2-cm-sized tumors or smaller) ranges from 6% to 36%. Predictors of axillary lymph node metastasis in patients with T1 tumors include tumor size, lymphovascular space involvement, and the histological grade of the lesion (e.g., in one report, 26.7% of patients with grade I, T1c tumors had metastatic disease to the axilla, compared with 35.7% of patients with grade III, T1c tumors).

 

Patient 28

Figure 2.31. Screening study, 45-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Double spot compression magnification views, craniocaudal projection, exaggerated laterally (XCCL) (C). T1-weighted, sagittal image (D), right breast, precontrast, and T1-weighted, sagittal image (E), right breast, 1 minute following intravenous bolus of gadolinium, same tabletop position as shown in (D). T1-weighted, saggital image (F), left breast precontrast, and T1-weighted image (G), left breast, 1 minute following intravenous bolus of gadolinium, same table top position as shown in (F). Ultrasound image (H), lower inner quadrant, left breast.

Are there any findings in the right breast?

Are there any findings in the left breast?

What would you recommend next?

A cluster of calcifications is present in the right breast. The cluster is best imaged on the mediolateral oblique view; it is partially visualized laterally on the right craniocaudal view. No abnormality is appreciated in the left breast. Additional evaluation with magnification views is indicated on the right.

BI-RADS® category 0: need additional imaging evaluation.

 

A cluster of pleomorphic calcifications of variable density, imaged on the exaggerated craniocaudal views laterally (XCCL) magnification view, is shown here. Some of the calcifications are linear and some demonstrate linear orientation. This is likely to represent a ductal carcinoma in situ with central necrosis.

BI-RADS® category 5: Highly suspicious of malignancy; appropriate action should be taken.

Appropriate action, in the form of a stereotactially guided biopsy, is taken. A high-nuclear-grade ductal carcinoma with central necrosis is diagnosed following the core biopsy. As with all of our patients diagnosed with breast cancer, magnetic resonance imaging (MRI) is undertaken to evaluate for the presence of multifocal or multicentric disease in the ipsilateral breast and to assess the contralateral breast.

 

How would you describe the imaging findings?

A focus of enhancement is noted posteriorly in the right breast, corresponding to the area of ductal carcinoma in situ detected mammographically. Kinetically, there is rapid wash-in and wash-out of contrast, consistent with a malignant process. Unexpectedly, a mass, characterized by rapid wash-in and wash-out of contrast, is imaged in the left breast. The patient is called back following the MRI for ultrasound evaluation of the left breast. Based on the MR images (i.e., slice thickness and relationship of lesion to nipple), the expected location of the lesion can be approximated prior to the ultrasound.

 

What do you think, and what is your recommendation?

An irregular 1-cm mass with indistinct margins is identified at the 7 o'clock position, 2 cm from the left nipple.

BI-RADS® category 4: Suspicious abnormality; biopsy should be considered.

An invasive mammary carcinoma is diagnosed following ultrasound-guided core biopsy.

A high-nuclear-grade ductal carcinoma in situ, associated with necrosis and calcifications measuring 2 cm in size, is confirmed following a lumpectomy on the right. Three excised sentinel lymph nodes are normal [pTis(DCIS), pN0(sn)(i—), pMX; Stage 0]. A grade I invasive ductal carcinoma measuring 1 cm is confirmed following a lumpectomy on the left. Two excised sentinel lymph nodes are normal [pT1b, pN0(sn)(i—), pMX; Stage 1].

What is the potential role of magnetic resonance imaging in patients diagnosed with breast cancer?

The routine use of magnetic resonance imaging preoperatively in patients with a known breast cancer diagnosis is helpful in further characterizing the extent of the disease and directing appropriate surgical management in some patients. Women with multicentric lesions confirmed to be either intraductal or invasive disease may be more appropriately managed with a mastectomy, and those with more extensive or multifocal disease may require wider excisions than initially planned. In the 5% to 6% of women identified with synchronous contralateral cancers, bilateral procedures are indicated.

For patients with MRI-detected lesions, the location of the lesion is approximated based on the MRI and a targeted ultrasound is done. If the lesion is identified, an ultrasound-guided biopsy can be done; otherwise, MR-guided biopsy, clip placement, or wire localization may be indicated.

 

Patient 29

Figure 2.32. Screening study, 43-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

What do you think?

Bilateral, symmetric spiculated masses are present with associated distortion. What could generate symmetric, almost identical findings in this location? What specific question would you ask the patient?

How about, did she have implants and were they removed?

Yes, she has had implants, and they have been removed. Mammographically, the findings following implant removal are variable. In some women, fluid collections may develop at the site of the implants; in others, portions of the capsule may be seen as curvilinear densities in the central aspect of the breasts posteriorly. Dense calcifications (dystrophic) may occur. Rarely, spiculated masses, presumably reflecting fat necrosis, may be present (as in this woman). Alternatively, the mammogram may be normal following implant removal.

BI-RADS® category 1: negative. BI-RADS® category 2: benign findings, is used if the observations are described in the report. Annual screening mammography is recommended.

 

Patient 30

Figure 2.33. Screening study, 65-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

What do you think, and what additional information would you like?

A focal area of parenchymal asymmetry is present in the upper central aspect of the left breast. It is in the same approximate distance from the nipple on both projections; however, it appears more spread out on the craniocaudal (CC) view. On the CC view, this area lacks the convex borders that are associated with most masses, and there is fat interspersed in the glandular tissue. In most patients, focal parenchymal asymmetry is a normal variant.

A good history is important. Has the patient had any breast surgery (e.g., a comparable area of tissue excised from the right breast), or does this finding reflect fat necrosis postsurgery at this site in the left breast? Is there any history of trauma to this site (e.g., hematoma)? Estrogen use? Presumably, if the patient had any focal tenderness, erythema, skin dimpling, or discoloration limited to this site, she would have been scheduled for a diagnostic evaluation or your technologist would have indicated this on the woman's history sheet.

What else would be helpful?

Comparison with prior studies is critical. If the area of focal parenchymal asymmetry represents a change, or if no prior studies are available for comparison, spot compression views and ultrasound with correlative physical examination are undertaken to exclude an underlying malignancy. If normal tissue is imaged on spot compression views and ultrasound, and there is no corresponding palpable abnormality on physical examination, no further intervention is recommended. Magnetic resonance imaging may also provide helpful information, particularly in high-risk patients in whom no definite mass is palpated but there is thickening or persistent concerns discerned during the physical examination at the site of the asymmetry. If concerns remain following the diagnostic evaluation, an imaging-guided biopsy can be undertaken.

Fibrosis or pseudoangiomatous stromal hyperplasia (PASH) is often the diagnosis on core biopsies done through these areas.

What is the differential diagnosis?

Differential considerations include normal variant, hormone replacement therapy effect, asymmetry secondary to prior surgical excision of the corresponding tissue in the right breast, focal fibrosis, pseudoangiomatous stromal hyperplasia (PASH), postsurgical or traumatic changes (evolving hematoma; fat necrosis), mastitis, fibroadenolipoma (hamartoma), invasive ductal carcinoma not otherwise specified, invasive lobular carcinoma, and lymphoma.

This area is unchanged from prior studies (not shown).

BI-RADS® category 1: negative. Annual screening mammography is recommended.

 

 

Patient 31

Figure 2.34. Screening study, 74-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Metallic BB on skin lesion, left breast. Craniocaudal (C) and mediolateral oblique (D) photographically coned views of the anterior aspect of the left breast. Craniocaudal (E) and mediolateral oblique (F) photographically coned views of the anterior aspect of the left breast; area of distortion is delineated by box. Craniocaudal (G) and mediolateral oblique (H) spot compression views, left breast. Ultrasound images in radial (RAD) (I) and antiradial (ARAD) (J) projections, left breast, corresponding to the site of mammographic concern.

What do you think?

In this patient, the potential abnormality may not be readily apparent. In these situations, it is particularly important to review the films systematically, looking specifically for a mass, calcifications, distortion, or asymmetry. Evaluate specific locations including medial quadrants on the craniocaudal views, fat-glandular interfaces, the fatty stripe of tissue between the pectoral muscle and the glandular tissue on the mediolateral oblique (MLO) views, the upper cone of tissue on the MLO views and the subareolar areas. You need to focus carefully: Unlike most masses and calcifications, the perception of distortion is difficult and requires special attention.

Focus your attention anteriorly. Look for straight lines and an overall disruption of tissue architecture. In some patients you may see what appear as small locules of fat clustered in the central aspect of the distortion as well as along the straightened trabecula. As you focus your search of the subareolar area, do you see the distortion?

 

How can you increase your perception skills for distortion?

One way to enhance your perception of distortion is to evaluate the mammograms of women who have had a prior surgical biopsy. Although in many of these women no abnormality is apparent, in a small number, subtle distortion can be seen at the biopsy site; looking for it will help you enhance your perception skills for subtle distortion. Previous films and a history of prior breast biopsies or trauma should be obtained. If the patient has not had a prior breast biopsy or significant trauma to the left subareolar area and this finding represents an interval change, additional evaluation is indicated.

BI-RADS® category 0: need additional imaging evaluation.

 

 

Do the compression views help?

How would you describe the imaging findings?

Distortion is confirmed on the spot compression views. An irregular, vertically oriented, hypoechoic, 2-cm mass with indistinct, angular, and microlobulated margins and associated shadowing is imaged at the 12 o'clock position, 2 cm from the left nipple.

BI-RADS® category 4: suspicious abnormality; biopsy should be considered.

An invasive lobular carcinoma is reported on the core samples. A 2.2-cm, grade I invasive ductal carcinoma with prominent lobular features is reported on the lumpectomy specimen. Three excised sentinel lymph nodes are normal [pT2, pN0(sn)(i—), pMX; Stage IIA].

 

Patient 32

Figure 2.35. Screening study, 55-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)views, 16 months prior to (A) and (B). Craniocaudal (E) and mediolateral oblique (F) spot compression views, right breast. Ultrasound images in radial (RAD) (G) and antiradial (ARAD) (H) projections, right subareolar area, corresponding to the site of mammographic concern. Ultrasound image in (RAD) (I) projection demonstrating ducts (arrows) extending from the mass in the subareolar area towards the nipple (“duct extension”). Ultrasound image in antiradial (ARAD) (H) projection demonstrating ducts branching (arrows) away from the mass/nipple (“branch pattern”).

Any observations?

A mass is present in the right subareolar area. If prior studies are available, comparison will be helpful. If this finding is new, additional evaluation is indicated. If this finding is stable, decreasing in size, or has previously been evaluated, additional evaluation may not be indicated.

 

What do you think, and what BI-RADS® assessment category would you assign?

The finding in the right breast represents a change. Additional evaluation with spot compression views and ultrasound is recommended.

BI-RADS® category 0: need additional imaging evaluation.

 

 

How would you describe the imaging findings, and how would you sort through the differential?

A mass with indistinct and obscured margins is imaged on the spot compression views. A hypoechoic mass, with angular margins and associated prominent ducts extending toward the nipple and branching away from the nipple (Fig. 2.35I, J) is imaged at the 10 o'clock position, 1 cm from the right nipple. A fibroadenoma is unlikely to develop in a 55-year-old woman, particularly if she is not on hormones, and the imaging features are not typical of a fibroadenoma. Although the patient has no history of nipple discharge, and none is elicited during the ultrasound study, a papillary lesion is a significant consideration given the subareolar location and the associated ductal changes noted on the ultrasound study. Focal fibrosis, pseudoangiomatous stromal hyperplasia (PASH), invasive ductal carcinoma not otherwise specified, mucinous, medullary, or papillary carcinomas are additional considerations. The bottom line? A solid mass developing in a postmenopausal woman requires biopsy.

BI-RADS® category 4: suspicious abnormality; biopsy should be considered.

An ultrasound-guided biopsy is done at the completion of the diagnostic evaluation.

Invasive ductal and intraductal carcinomas are reported on the ultrasound-guided core biopsy. A 1.5-cm grade I invasive ductal carcinoma and associated solid and cribriform ductal carcinoma in situ without necrosis are reported on the lumpectomy specimen. Micrometastatic disease detected on the hematoxylin-eosin (H&E) slides (>0.2 mm but <2 mm in size) is reported in two of three excised sentinel lymph nodes (pT1c, pN1mi, pMX; Stage IIB).

 

What changes in the handling of lymph node specimens have been seen with the introduction of sentinel lymph nodes biopsies?

The advent and now widespread use of sentinel lymph node biopsy has resulted in a more meticulous evaluation of the excised lymph node(s). This includes serial sectioning of the entire lymph node (as opposed to sample sections from multiple lymph nodes) and a more focused histologic and immunohistochemical (IHC) evaluation of the excised lymph node. Some of the effects of this more thorough pathologic evaluation include the observation of isolated tumor cells and micromestatic disease. Consequently, the significance of these findings (isolated tumor cells and micrometastasis) involving excised sentinel lymph nodes is not yet clear, and there is no consensus on their prognostic significance. Currently, the use of IHC evaluation of sentinel lymph nodes is not encouraged; however, it is done at many institutions. The determination of micromestatic disease should be based on routine H&E histologic evaluation.

 

Patient 33

Figure 2.36. Screening study, 52-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Mediolateral oblique (C) and craniocaudal (D)views. The potential abnormality noted in the mediolateral oblique view is measured to be “X” cm posterior to the nipple. If there is a corresponding abnormality on the craniocaudal view, one can expect to find it along a line drawn to “X” cm from the nipple. A potential corresponding area of asymmetry is found in the craniocaudal view, within the box. Craniocaudal (E) and mediolateral oblique (F) spot compression views, left breast. Ultrasound images, radial (RAD) (G) and antiradial (ARAD) (H) projections corresponding to the area of mammographic concern.

 

What do you think?

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

Review the images carefully, using a systematic approach. Divide the images in thirds so that you focus your attention on smaller portions of the mammograms and look specifically for masses, calcifications, asymmetric areas, distortion, and diffuse changes section by section. Do you notice anything? How about an area of asymmetry on the left, when you evaluate the upper third of the mediolateral oblique (MLO) views? Is there a comparable potential abnormality on the left craniocaudal (CC) view? How can you determine this? Although you can measure with a ruler, an easier way is to determine how many finger breadths behind the nipple the lesion is located on the MLO, making sure your fingers are positioned so that they are parallel to the edge of the pectoral muscle. For me, this lesion is three finger breadths posterior to the nipple (“X” cm, Fig. 2.36C). On the CC view, if I place my three fingers parallel to the edge of the film (“X” cm, Fig. 2.36D), the potential lesion will probably be somewhere along the course of my fingers (i.e., on a line drawn perpendicular to the arrow, Fig. 2.36D). This is obviously a rough measure, but it is helpful in determining if observations you make on one view have a corresponding potential finding on the other projection. In this patient, there is a potential abnormality noted on the CC view (box). This may be superimposed glandular tissue; however, with what degree of certainty can we establish this on the screening views? Do we mention it on the report, hedge and let it go, or do we call the patient back for additional views?

BI-RADS category 0: need additional imaging evaluation.

 

 

What do you think now?

Are you surprised?

The spot compression views demonstrate a 1-cm area of distortion corresponding to the area of concern on the screening study. In the absence of a history of a surgical biopsy or significant trauma at this site, correlative physical examination and ultrasound are undertaken.

 

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

A vertically oriented, irregular, hypoechoic mass with indistinct margins and shadowing is consistently imaged at the 1 o'clock position, 4 cm from the left nipple. This corresponds to the area of mammographic concern. There is no corresponding palpable abnormality detected as this area is scanned.

BI-RADS® category 4: suspicious abnormality; biopsy should be considered.

An invasive lobular carcinoma is diagnosed following ultrasound-guided core biopsies. A 4.2-cm invasive lobular carcinoma is reported on the lumpectomy specimen; associated atypical lobular hyperplasia is present. No metastatic disease is diagnosed in two excised sentinel lymph nodes [pT2, pN0(sn)(i—), pMX; Stage IIA].

What do you think about the size described pathologically?

Does this correlate with the imaging findings?

Why not?

This is one of the reasons I call invasive lobular carcinoma the “sleaze disease.” Small monomorphic cells that invade tissue in single files without forming nests of cells or disrupting surrounding structures characterize invasive lobular carcinoma histologically. Consequently, invasive lobular carcinomas can be clinically, mammographically, and pathologically (the invading cells can resemble lymphocytes) subtle. When we see something mammographically, the findings commonly underestimate the extent of disease found histologically (i.e., what we see mammographically is often the tip of the iceberg).

 

Patient 34

Figure 2.37. Screening study, 73-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

What are the pertinent observations, and what is your working hypothesis?

Global parenchymal asymmetry is present in the right breast. The left breast is smaller and there is subtle distortion on the left, such that the prior breast surgical history should be reviewed. In this patient, the findings are iatrogenic. The patient has had a biopsy in the left breast, so the tissue on the right is now asymmetric. Following excisional biopsies, no mammographic abnormality is apparent in >50% of the patients. Changes that can be seen following an excisional biopsy include a decrease in size of the affected breast, localized skin thickening and retraction, architectural distortion, a spiculated or mixed-density (fat containing) mass, oil cysts, dystrophic calcifications, and areas of focal or global parenchymal asymmetry in the contralateral breast.

BI-RADS® category 1: negative. In general, for benign findings, if the observations represent a change from the prior mammogram, I describe them in the report and use BI-RADS® category 2: benign finding. If the findings are stable compared with prior mammograms, I do not describe them and use category 1 for the assessment. Annual screening mammography is recommended.

 

Patient 35

Figure 2.38. Screening study, 73-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)spot compression views, right breast. Ultrasound image, radial (RAD) (E) projection and ultrasound image, radial projection (F).

 

Is this a normal mammogram, or is it potentially abnormal?

How many lesions do you think may be present, and with what degree of certainty can you determine the significance of any finding?

A mass is present in the upper outer quadrant of the right breast (or, given the craniocaudal view, are there two?). Although you might be tempted to think that this is an intramammary lymph node, remember—make no assumptions! Is this mass well circumscribed? Can you unequivocally identify a fatty hilum? Can you establish the stability of this finding? Without prior films, which are not available, the stability of this finding cannot be determined. On the current study, it is not possible to confidently describe the margins as well circumscribed, nor can the presence of a fatty hilum be established; consequently, additional evaluation is indicated.

BI-RADS® category 0: need additional imaging evaluation.

 

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

The spot compression views confirm the presence of two masses with indistinct margins. On ultrasound, the larger of the two masses (Fig. 2.38E) is irregular in shape, vertically oriented, and characterized by angular margins. The smaller of the two masses (within box, Fig. 2.38F) is round with small spiculations. Both masses are at the 10 o'clock position, zone 2 in the right breast.

BI-RADS® category 4: suspicious abnormality; biopsy should be considered.

An invasive mammary carcinoma is reported on the core biopsy samples. A 1.2-cm grade III invasive mammary carcinoma, micropapillary type, is reported on the lumpectomy specimen. No metastatic disease is diagnosed in one excised sentinel lymph node [pT1c, pN0(sn)(i—), pMX; Stage I].

Invasive micropapillary carcinoma is a recently described entity. Unlike this patient, most of the patients described in the literature with this type of tumor have associated involvement of the axillary lymph nodes. As a result, this type of carcinoma has been associated with a poor prognosis.

 

Patient 36

Figure 2.39. Screening study, 74-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)views, limiting the evaluation to the medial and inferior thirds of the breasts. This helps focus attention on smaller amounts of tissue and enables you to go back and forth between the right and left breasts looking for masses, areas of parenchymal asymmetry, distortion, and calcifications. Craniocaudal (E)and mediolateral oblique (F) views. With the identification of an area of parenchymal asymmetry, medially in the left craniocaudal view, you can use your fingers to estimate the distance of this area from the nipple. Now, go to the mediolateral oblique view and, angling your fingers so that they are parallel to the obliquity of the pectoral muscle, you can identify a corresponding abnormality at the edge of your finger inferiorly on the mediolateral oblique view. Craniocaudal (G) and mediolateral oblique (H), spot compression views. Ultrasound images in radial (I) and antiradial (J) projections at the 7 o'clock position, 4 cm from the left nipple.

 

What is the main observation?

Divide the images in thirds (Fig. 2.39C, D) so that you focus your attention on smaller portions of the mammograms and look specifically for masses, calcifications, asymmetric areas, distortion, and diffuse changes in a systematic progression. Asymmetric tissue is imaged medially in the left breast on the craniocaudal view.

Is there a corresponding area on the left mediolateral oblique view?

Use your fingers to approximate the distance from the nipple back to the asymmetric area on the craniocaudal (CC) view (Fig. 2.39E). Now, go to the mediolateral oblique (MLO) view and, angling your fingers (Fig. 2.39F) so that they are parallel to the obliquity of the pectoral muscle, look for a corresponding abnormality at the edge of your finger—do you see it? Before calling the patient back, prior films (not shown) are reviewed and indicate that this is an interval change.

BI-RADS® category 0: need additional imaging evaluation.

 

 

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

The spot compression views confirm the presence of a 1.5-cm mass with indistinct margins. On ultrasound, the mass is nearly isoechoic; however, it is detected and characterized by an irregular shape and angular margins.

BI-RADS® category 4: suspicious abnormality; biopsy should be considered.

An invasive mammary carcinoma with focal mucinous features is reported on the core biopsies. A 1.2-cm, grade II invasive ductal with mucinous features is reported on the lumpectomy specimen. Associated solid and cribriform ductal carcinoma in situ with no necrosis is also reported. The sentinel lymph node is normal [pT1c, pN0(sn)(i—), pMX; Stage I].

 

Patient 37

Figure 2.40. Screening study, 59-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)double spot compression magnification views, right breast.

 

Is this mammogram normal?

Review the images systematically:

1. Technically, is this an adequate study? Positioning is not optimal, particularly on the mediolateral oblique (MLO) views; however, the images are adequate.

2. Are there diffuse changes?

3. Evaluate specific locations: (a) medial quadrants on the craniocaudal views; (b) fat-glandular interfaces; (c) fatty stripe of tissue between anterior edge of pectoral muscle and glandular tissue on the MLO views; (d) subareolar areas; and (e) superior cone of tissue on the MLO views.

4. Splitting the images in thirds, look for specific lesions: (a) masses; (b) calcifications; (c) distortion; and (d) islands of asymmetry.

Is this a normal study?

What is indicated next (be specific)?

BI-RADS® category 0: need additional imaging evaluation. Magnification views in two projections are indicated for further evaluation.

 

A cluster of pleomorphic calcifications is confirmed on the double spot compression magnification views. There are linear calcifications characterized by irregular margins and clefts. Additionally, linear and round calcifications demonstrate linear orientation. This represents at least ductal carcinoma in situ until proven otherwise.

BI-RADS® category 5: Highly suggestive of malignancy; appropriate action should be taken.

Appropriate action is taken in the form of a stereotactically guided biopsy. A high-nuclear-grade ductal carcinoma in situ with associated central necrosis is reported. This diagnosis is confirmed on the lumpectomy specimen [pTis(DCIS), pNX, pMX; Stage 0]. No invasive disease is diagnosed. No sentinel lymph node biopsy is done.

Patient 38

Figure 2.41. Screening study, 41-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

How would you describe the findings on this mammogram?

Global parenchymal asymmetry can be described in the right breast. Establishing the presence of global parenchymal asymmetry requires comparison with the contralateral side. A greater volume of tissue is present in the right breast compared to the same area in the left breast. As defined in the Fourth Edition of BI-RADS®, global asymmetry should involve at least a quadrant of the breast. Although breast tissue is more commonly symmetric, global asymmetry, as demonstrated here, can be seen in a small number of woman as a normal variant. No mass or distortion is noted in the area of increased tissue on the right. The tissue in this area is scalloped and contains associated areas of fatty lobulation. Comparison with prior studies is helpful in assessing the stability of this finding.

What piece of information is critical in this patient?

What BI-RADS® category would you use for this mammogram?

In women with global or focal parenchymal asymmetry, it is critical to establish that there is no palpable abnormality corresponding to the area of parenchymal asymmetry. If there is any question about a corresponding palpable abnormality, the patient can be asked to return for correlative physical examination and, if needed, additional mammographic images, ultrasound, or, occasionally, magnetic resonance imaging.

BI-RADS® category 1: negative. In general, for benign findings, if the observations represent a change from the prior mammogram, I describe them in the report and use BI-RADS® category 2: benign finding. If the findings are stable compared with prior mammograms, I do not describe them and use category 1 for the assessment. Annual screening mammography is recommended for this patient.

 

Patient 39

Figure 2.42. Screening study, 46-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) views with a box on possible mass with distortion. Mediolateral oblique views (D), with box delineating asymmetry involving the upper cone of tissue on the right breast. Craniocaudal (E) and mediolateral oblique (F) spot compression views, right breast. Ultrasound images, radial (RAD) (G) and antiradial (ARAD) (H) projections, corresponding to the site of the mass seen mammographically in the right breast.

 

What observations can you make, and what would you like to do next?

A mass is present in the left breast, best seen on the craniocaudal (CC) view, directly posterior to the nipple. Are there any other observations? Review the images systematically. Focus your attention on smaller amounts of tissue by splitting the CC and mediolateral oblique (MLO) views into thirds. Look for specific findings, including diffuse changes, masses, distortion, asymmetry, and calcifications. Review areas on the mammograms where breast cancers are likely to develop, specifically, fat-glandular interfaces, the fatty stripe of tissue between pectoral muscle and glandular tissue on MLO views, the superior cone of tissue on MLO views, medial tissue on CC views, and subareolar areas. Focus down with a magnification lens, particularly when looking for small masses, distortion, and clusters of calcifications. Is there a potential mass with distortion in this patient? Where? On the CC views, review the fat-glandular interfaces particularly abutting the retroglandular area on the right (Fig. 2.42C). On the MLOs, look at the upper thirds of the MLOs and more specifically at the upper cone of tissue on the right MLO (Fig. 2.42D). Do you see the mass? Do you see the distortion? Additional evaluation is indicated bilaterally.

BI-RADS® category 0: need additional imaging evaluation.

 

 

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

The 1.2-cm mass in the left breast is a cyst (images not shown) and requires no further intervention. The spot compression views on the right confirm the presence of an irregular 2.5-cm mass with associated distortion and low-density amorphous calcifications (Fig. 2.42E, F). On ultrasound, an irregular, hypoechoic mass with areas of shadowing is imaged at the 12:30 o'clock position, 12 cm from the right nipple (Fig. 2.42G, H).

BI-RADS® category 5: Highly suggestive of malignancy; appropriate action should be taken.

Appropriate action is taken in the form of an ultrasound-guided core biopsy. Histologically, an invasive mammary carcinoma is reported on the cores. A grade II, invasive ductal carcinoma measuring 2.7 cm is reported on the lumpectomy specimen. Associated intermediate-grade, solid-type ductal carcinoma in situ is also present. Two excised sentinel lymph nodes are negative for metastatic carcinoma [pT2, pN0(sn)(i—), pMX; Stage IIA].

 

Patient 40

Figure 2.43. Screening study, 76-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. A metallic BB on the left marks a skin lesion. Craniocaudal (C) views. Limiting evaluation to the medial quadrants of the breasts focuses your evaluation on smaller amounts of tissue. Now look specifically for a possible mass. Craniocaudal (D) spot compression view, left breast. Ultrasound images, in radial (RAD) (E) and antiradial (ARAD) (F)projections at the 7 o'clock position, 9 cm from the left nipple.

 

What do you think?

What, if anything, would you like to do next?

Review the films systematically. There are scattered dystrophic calcifications and arterial calcifications bilaterally. Focus your attention on smaller amounts of tissue by splitting the craniocaudal (CC) and mediolateral oblique (MLO) views into thirds. Look for specific findings, including diffuse changes, masses, distortion, asymmetry, and calcifications. Review areas on the mammograms where breast cancers are likely to develop, specifically, fat-glandular interfaces, the fatty stripe of tissue between pectoral muscle and glandular tissue on MLO views, the superior cone of tissue on MLO views, medial tissue on CC views, and subareolar areas. Focus down with a magnification lens, particularly when looking for small masses, distortion, and clusters of calcifications. Do you notice anything when you evaluate medial tissue on the CC views (Fig. 2.43C)? How about at the edge of the film on the left? Because there is nothing readily apparent on the MLO view, are you comfortable describing this as a normal mammogram? With what degree of certainty can you dictate a report on this screening study? Could a lesion have been excluded on the MLO view?

BI-RADS® category 0: need additional imaging evaluation.

Do you see it?

 

 

How would you describe the findings?

The spot compression view confirms the presence of a spiculated mass posteromedially in the left breast. Based on this information, what is your degree of certainty that there is a significant abnormality and that a biopsy is indicated? Is it now possible to dictate a succinct, definitive, and directive report? On ultrasound, a hypoechoic spiculated mass, with intense shadowing and vertical orientation, is identified at the 7 o'clock position, 9 cm from the left nipple.

Time and time again, you will find that by following a simple, logical process, and completing the image workup, you will deliver optimal patient care that minimizes the likelihood of delaying the diagnosis of breast cancer.

This patient illustrates the need to focus keenly on tissue extending to the edge of the films. The fact that this lesion is not imaged on the MLO view should not dissuade you from calling the patient back. With far posteromedial lesions, it is common to partially (barely) image them on only one of the two routine views. Usage of the spot compression paddle often allows more tissue to be included on the image.

With respect to imaging this lesion on the orthogonal view, what view might be helpful and why?

Be specific

When considering 90-degree lateral views, there are two possibilities: a 90-degree lateromedial (LM) or a 90-degree mediolateral (ML) view. For the 90-degree LM view, the bucky is placed up against the sternum so that a maximal amount of medial tissue is included on the image and, because medial tissue is closest to the film, resolution of medial lesions is improved. For the 90-degree ML view, the bucky is placed laterally and compression is applied medially. In this patient, a 90-degree LM view provides the best chance to image the lesion on the orthogonal view.

BI-RADS® category 4: suspicious abnormality; biopsy should be considered.

Rather than just consider biopsy, one is undertaken using ultrasound guidance. An invasive ductal carcinoma is diagnosed on the core samples. A 1.2-cm, grade I invasive ductal carcinoma is reported on the lumpectomy specimen. No metastatic disease is reported in three excised sentinel lymph nodes [pT1c, pN0(sn)(i—), pMX; Stage I].

 

Patient 41

Figure 2.44. Screening study, 57-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)views, screening study 2 years prior to (A) and (B). No history of breast surgery or trauma. Craniocaudal (E) and mediolateral oblique (F) views. There is a mass in the left breast (arrows). This represents a change from the prior study and therefore also requires evaluation. Repeat craniocaudal (G) views. With better positioning, the lesion is now seen in this projection laterally. Mediolateral oblique (H) spot compression view, right breast. Craniocaudal (I)and mediolateral oblique (J) spot compression views, left breast. Mediolateral oblique (J) spot compression views left breast. Ultrasound image, antiradial (K) projection, right breast at the 10 o'clock position approximately 8 cm from the right nipple. Ultrasound image, antiradial (ARAD) (L) projection, left breast.

 

What are your observations?

An asymmetry with irregular margins is imaged in the right mediolateral (MLO) view anterior to the pectoral muscle; however, there is no corresponding abnormality on the craniocaudal (CC) view. Are there any other observations? Is breast positioning optimal on the CC views? How can you tell? Do you see pectoral muscle in either CC view? Do you see cleavage in either CC view? When you cannot see pectoral muscle or cleavage on CC views, you must consider the possibility that posterior tissue has been excluded from the image. Under these circumstances, you should measure the posterior nipple line (PNL). The PNL measurement on the CC view should be within 1 cm of that measured on the MLO view (Fig. 2.4E, F). If the measurements are not within a centimeter of each other, posterior tissue has been excluded and the CC image needs to be repeated. In this patient, posterior tissue has been excluded from both CC views and, with it, possibly a lesion. The CC views need to be repeated.

Do you have any other observations?

What else would you like at this point?

How about prior studies? Ideally, when you observe a potential abnormality on a screening study, you should review prior films and determine if the patient has had any surgery or trauma localized to the site of concern. Although it would be appropriate to call this patient back for further evaluation if there are no prior studies or they are unavailable, you do not want to recall patients in whom the potential abnormality has decreased in size, been previously evaluated, or if it reflects postoperative changes.

P.211

 

What do you think?

Does the patient need additional evaluation?

The area of asymmetry has increased in size compared to the prior study and, with better positioning on the CC views, it can be seen on the prior CC view. In comparing the two studies, do you have any other observations? What is the next step?

BI-RADS® category 0: need additional imaging evaluation.

The patient is called back for further evaluation. Did you notice the new nodule in the left breast (Fig. 2.44E, F, arrows)? What will you ask the technologist to do on the right? How about on the left?

 

 

What can be done to maximize visualization of lateral tissue on craniocaudal views?

The lesion in the right breast was excluded from the field of view on the initial craniocaudal (CC) view. Repeat CC views, with a tug on the lateral aspect of the breast, will maximize the amount of lateral tissue included on the images. Alternatively, an exaggerated craniocaudal view, laterally (XCCL), can be done. The XCCL view can be done using the large compression paddle or a spot compression paddle. When positioning patients for CC views, it is important for the mammographic technologist to identify the inframammary fold (IMF) and lift the breast as much as the natural mobility of the IMF permits. Additionally, the technologist needs to pull the tissue out away from the body and routinely tug on the lateral aspect of the breast to maximize the amount of posterolateral tissue included on the images. If, after the lateral tug is done, tissue is still seen extending to the edge of the film laterally, and there is tissue posteriorly superimposed on the pectoral muscle on the MLO view, an XCCL view may be indicated.

 

 

How would you describe the findings?

Spot compression views, bilaterally, confirm the presence of bilateral lesions. The mass on the right is irregular with spiculated margins and some associated calcifications and measures approximately 2 cm. A hypoechoic mass with intense shadowing, an echogenic halo, vertical orientation, and spiculation is identified on ultrasound at the 10 o'clock position, 8 to 10 cm from the right nipple. The mass on the left is round with indistinct and possibly microlobulated margins and measures approximately 0.7 cm. An irregular, hypoechoic mass, with angular margins and an echogenic halo, is found in the left breast at the 4 o'clock position, 5 cm from the nipple. This corresponds to the expected location of the lesion seen mammographically in the left breast. Biopsies are indicated bilaterally. Be mindful of any developing solid mass in postmenopausal women, particularly if they are not on hormone replacement therapy.

BI-RADS® category 4: suspicious finding; biopsy should be considered.

Imaging-guided biopsies are done bilaterally. Invasive and intraductal carcinomas are reported bilaterally on the ultrasound-guided core samples.

How are multifocality and multicentricity defined?

How about synchronous and metachronous lesions?

What is emerging as the modality of choice in evaluating patients diagnosed with breast cancer?

If you identify one suspicious (and obvious) finding, be sure to continue looking at the mammogram for other lesions bilaterally. Multifocal lesions occur in the same quadrant and multicentric lesions are found in different quadrants in the same breast. Bilateral breast cancers are synchronous if they are diagnosed at the same time and metachronous if they are diagnosed after an arbitrary interval (e.g., 6 or 12 months from the initial cancer diagnosis). The published literature relative to the incidence of multifocality and multicentricity is limited and difficult to review because there are significant differences in how the terms are defined and how tissue is evaluated histologically. There are now good data supporting the use of magnetic resonance imaging (MRI) in evaluating patients for multifocal, multicentric, and synchronous contralateral lesions, all of which could change the surgical management of the patient. We recommend bilateral breast MRI in all of our patients with a new diagnosis of breast cancer.

 

Patient 42

Figure 2.45. Screening study, 40-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.

 

What observations can you make, and what underlying condition do you think the patient has?

The left breast is smaller than the right, and there is no pectoral muscle imaged on the left. In some patients, the pectoral muscle may not be imaged secondary to a history of prior trauma (e.g., a burn) to the chest wall or shoulder, or a stroke, such that the patient is unable to cooperate with positioning. Alternatively, Poland's syndrome should be considered. This patient has no history of trauma or stroke. She has Poland's syndrome.

Poland's syndrome is a rare, sporadic congenital malformation with unilateral hypoplasia of the chest wall, ipsilateral hand abnormalities, absence of the costosternal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, and absence of the second, third, and fourth or third, fourth, and fifth costal cartilages or ribs. The clinical manifestations of Poland's syndrome are variable. It is postulated that hypoplasia or damage to the subclavian artery, or its branches, in utero leads to the range of developmental abnormalities reported in these patients. Mammographic manifestations in this syndrome include hypoplasia of the ipsilateral breast, inability to visualize the pectoralis muscle, and absence of a nipple. Association with malignancies including leukemia, lymphoma, and leiomyosarcoma has been reported in these patients. There have also been several case reports of breast cancer identified in women with Poland syndrome.

BI-RADS® category 1: negative. In general, for benign findings, if the observations represent a change from the prior mammogram, I describe them in the report and use BI-RADS® category 2: benign finding. If the findings are stable compared with prior mammograms, I do not describe them and use category 1 for the assessment. Annual screening mammography is recommended in this patient.

 

Patient 43

Figure 2.46. Screening study, 78-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Comparison screening study, 2 years previously. Craniocaudal (C) and mediolateral oblique (D) views.

 

Is this a normal mammogram?

A pacemaker is present in the left subpectoral region and there are scattered dystrophic and vascular calcifications. Before focusing your attention on the search for subtle signs of breast cancer, consider evaluating the study for technical adequacy and the presence of diffuse changes. When they are bilateral, diffuse changes can be hard to perceive. Did you notice the prominence of the trabecular markings? This becomes particularly striking when you compare with a study from 2 years previously.

 

What is your differential?

Differential considerations for diffuse changes that are usually unilateral, although rarely can be bilateral, include radiation therapy effect, inflammatory changes (e.g., mastitis), trauma, ipsilateral axillary adenopathy with lymphatic obstruction, dialysis shunt in the ipsilateral arm with fluid overload, invasive ductal carcinoma not otherwise specified, inflammatory carcinoma, invasive lobular carcinoma, or lymphoma. Invasive lobular carcinoma can lead to increases in breast density and size or a decrease in breast size (the shrinking breast). Differential considerations for diffuse changes that are usually bilateral, although they can be unilateral, include hormone replacement therapy (e.g., estrogen), weight change, congestive heart failure, renal failure with fluid overload, and superior vena cava syndrome. Additional rare benign causes include granulomatous mastitis, coumadin necrosis, arteritis, and autoimmune disorders (e.g., scleroderma). Obtaining a thorough history, examining the patient, and an ultrasound are often helpful in sorting through the differential considerations.

In this patient, the findings reflect congestive heart failure with fluid overload. Signs and symptoms improve significantly with diuretics; this applies to the mammographic changes as well.

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

 

Patient 44

Figure 2.47. Screening study, 66-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Mediolateral oblique, photographically coned view (C), left breast.

 

What is the diagnosis?

A serpiginous tubular structure is imaged in the upper outer quadrant of the left breast associated with scattered coarse calcifications. This is most likely a thrombosed vein (varix) reflecting healed Mondor's disease. In most patients, Mondor's disease resolves completely, with no residual imaging finding. Rarely, calcification may be seen outlining the thrombosed vein.

What is Mondor's disease?

Mondor's disease is a self-limiting, uncommon trombophlebitis involving one of the superficial veins in the breast. The thoracoepigastric and lateral thoracic veins are the most commonly involved. In most patients, the cause is idiopathic. However, reported causes of Mondor's disease include breast trauma, breast surgery, imaging-guided biopsies, sentinel lymph node biopsy, dehydration, excessive physical activity, an inflammatory process, and, rarely, breast cancer.

What is the clinical presentation of Mondor's disease, and what imaging findings can be seen?

What is the treatment of choice?

Acutely, patients with Mondor's disease describe a tender cord that is often associated with linear dimpling, accentuated when the ipsilateral arm is raised, or superficial serpiginous nodularity (simulating the appearance of a varicose vein) corresponding to the course of the involved vein. Mammographically, the affected vein may have a rope- or beadlike appearance. On ultrasound, a superficial beaded tubular structure may be imaged, corresponding to the linear dimpling. Mondor's disease typically resolves spontaneously. Patients are reassured of the likely benign nature of this condition and supported with nonsteroidal, anti-inflammatory agents for symptomatic relief of associated tenderness.

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

 

Patient 45

Figure 2.48. Screening study, 54-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views. Craniocaudal (C) and mediolateral oblique (D)views, 2 years previously.

What observations can you make, and what would you like to do next?

Lymph nodes and the pectoralis minor muscles (triangular densities at the edge of the mediolateral oblique views) are imaged bilaterally, superimposed on the pectoralis major muscles. More important, masses are present bilaterally. Comparison with prior studies is important to determine if these represent an interval change, in which case additional evaluation is indicated. If the masses are stable or decreasing in size, or if they have been previously evaluated, no further evaluation may be needed.

 

Based on the prior studies, what would you recommend next?

When compared with sequential prior studies (only one prior study is shown), multiple masses are seen bilaterally with notable size fluctuations. These have been evaluated with ultrasound previously and therefore no further evaluation is indicated at this time, particularly because they have almost completely regressed. Cysts are common and can occur at any age, including during adolescence. In many women, however, cysts develop, or become more prominent, during the perimenopausal period. If no hormone replacement is used, most cysts regress spontaneously following menopause. A second, smaller peak of cyst development is seen in women in their mid to late 70s and early 80s.

How should women with multiple similar masses on a screening mammogram be managed?

The management of women with multiple masses on screening mammograms is controversial. Given a low yield of malignancy, some suggest that no evaluation is indicated, provided the masses are similar in appearance mammographically. My approach to women with multiple masses is to evaluate them at the first presentation with spot compression views and ultrasound. If the masses are cysts, annual screening mammography is recommended. Thereafter, only new masses are evaluated with spot compression views and ultrasound. If one or more likely benign solid masses are imaged on ultrasound, a follow-up ultrasound is recommended in 6 months. A biopsy is done when a mass is solid and does not fit the criteria for a probably benign lesion following a complete workup.

BI-RADS® category 1: negative. Next screening mammogram is recommended in 1 year. (If for some reason the masses are described in the report, a BI-RADS® category 2: benign findings assessment is used and annual mammography is recommended).

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