Clinical Breast Imaging A Patient Focused Teaching File

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A Patient Focused Teaching File

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Gilda Cardeñosa, M.D

Professor of Radiology
Director of Breast Imaging
Department of Radiology
Virginia Commonwealth University Health System
Medical College of Virginia Hospitals
Richmond, Virginia

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Cardenosa, Gilda.
Clinical breast imaging : a patient focused teaching file / Gilda Cardenosa
p. ; cm.
Includes bibliographical references and index.
ISBN-10:0-7817-6267-7 (alk. paper)
ISBN-13:978-0-7817-6267-0
1. Breast—Imaging—Atlases. 2. Breast—Radiography—Atlases. 3. Breast—
Cancer—Diagnosis—Atlases. I. Title.
[DNLM: 1. Breast Diseases—radiography—Atlases. 2. Mammography—methods—
Atlases. 3. Ultrasonography, Mammary—methods—Atlases. WP 17 C266c 2007]
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To Mary Jones and Roxanne Aton
Your courage is inspirational, your impact profound. You light the path and motivate so
many of us to work relentlessly with gentle passion, quiet strength, steadfast commitment,
and serene humility to make a difference, one patient at a time.
Thank you.
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Last H1 Head vii
Contents
Preface ix
Acknowledgments xi
1 My Aunt Minnie 1
2 Screening 72
3 Diagnostic Breast Imaging 227
4 Management 377
Appendix: Breast Cancer TNM Classification and Stage Grouping 493
Patient List 495
Index 499
vii
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Preface
inston Churchill described writing a book as an adv enture: radiology and breast imaging. The concept of the clinical breast
W “To begin with, it is a toy and an amusement; then it becomes
a mistress and then it becomes a master, and then a tyrant. The last
imager is rooted in the fi m conviction that as breast imagers w e
make an incredibly valuable contribution to patient care—and y et,
phase is that just as you are about to be reconciled to your servitude, by virtue of our pivotal position in potentially bridging clinical and
you kill the monster and fling him out to the pu lic.” This is so! pathologic findings, with xpanding imaging capabilities, there is
Writing a book is solitary work that grabs hold of you and quickly so much more that we can do to revolutionize patient care and the
consumes your every waking moment and frequentl y haunts your manner in which that care is delivered. We must first, h wever, rec-
dreams. In the end, as “you kill the monster and fling him out to th ognize our unique position, embrace the challenges, and spearhead
public,” you can only hope fervently that what you thought needed the journey. Clinical breast imaging is a mo vement that is hard to
to be written, and the manner in which you chose to present your stop, because it is the right thing to do.
ideas, is useful but, most important, challenges others to think crit- I have arbitrarily divided the book into four chapters: “ My Aunt
ically about the concepts presented. Minnie,” “Screening,” “Diagnostic Breast Imaging,” and “Manage-
The effect of breast imaging, and the role of radiolo gists, in the ment.” Chapter 2, “Screening,” discusses our approach to screening
management of w omen with breast cancer goes unstated and , in studies and potential abnor malities detected on screening mammo-
many ways, misrepresented. There is continued skepticism and crit- grams. Because I wanted each patient presented to stand independ-
icisms relative to our contributions to patient care and the signifi ently, there is repetition of basic concepts, but my aim was to build a
cance of what has already been accomplished: the routine identifi strong infrastructure from which you can advance the care of y our
cation of small, lymph node–negative, stage 0 and stage I in vasive patients and the field of breast imaging. It is also impotant to empha-
cancers and ductal carcinoma in situ. Prior to the advent of high- size that although this book is di vided into chapters, the di vision is
quality mammography, some breast diseases such as ductal carci- arbitrary. Presenting screening mammograms without the diagnostic
noma in situ (DCIS) were considered “rare” and our understanding evaluation, when one is indicated, makes little sense to me; I cannot
of these diseases was limited. As a direct result of screening mam- squander invaluable opportunities to teach and car ry the discussion
mography, DCIS is routinely diagnosed and our knowledge, relative to appropriate completion. Consequently, there is overlap: Diagnostic
to the heterogeneity of this disease, has exploded. Recently reported and management issues are discussed in the chapter on screening,
decreases in breast cancer mor tality rates are attributed by many to and screening studies are presented in the diagnostic and manage-
more effective treatment, ignoring or relegating to a secondary role ment chapters. Management issues are discussed in the diagnostic
our ability to detect DCIS, stage 0, and stage I lesions in man y chapter. The differentials listed are not intended to be exhaustive lists
patients. Is early detection possibly the more important factor, and but rather, reasonable possibilities for one or multiple findings. It i
does not our ability to identify small lesions increase available treat- also important to recognize that the situation presented here is, b y
ment options for patients and render them more effective? necessity, artificial: Unlike what is presented here, in a screening
Clinical Breast Imaging: A Patient-Focused Teaching File pre- population, most mammograms are normal; and although the inci-
sents a clinically oriented, common-sense approach to screening, dence of cancer is higher in a diagnostic patient population, many
diagnostic evaluation, and the management of patients with breast patients are also normal or have benign changes and not cancer.
conditions encountered commonly by breast-imaging radiologists. In an era when high technology dominates the interest of radiol-
What is presented reflects a philosophical approach to breast imag ogy residents, I can only encourage them strongly to consider breast
ing, centered on empathy for patients, who deserve complete eval- imaging as a wonderful opportunity to make a powerful and signif-
uations and prompt answers, never forgetting that we are first an icant difference in the lives of their patients.
foremost physicians and clinicians, albeit with focused training in GILDA CARDEÑOSA
ix
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Acknowledgments
ver the years I have been helped, supported, encouraged, and and personal trials, has steadfastly, and without ever casting judg-
O inspired by many colleagues. In par ticular, I w ould like to
acknowledge Drs. Christine Q uinn, Michael Lin ver, Ellen
ment, supported and believed in my life's work and me.
When asked what the three most important things for parents to
Mendelson, Gillian Newstead, Regina O'Brien, Edward Hendrick, do when raising children are, Alfred Schweitzer responded,
G. W. Eklund, Peter Dempsey, Robert Schmidt, Cindy Lorino, “Example, example and example.” This is what my mother, Gilda
Barbara Schepps, Martha Mainiero, Phillip Murphy, Stephen Feig, Paniza Cardeñosa, provided many times over: I owe everything I
Jacqueline Hogge, Rebecca Zuurbier, Anne Roberts, Celia Parodi, am to her. Always with a smile on her face and a joke up her sleeve,
Mirta Lanfranchi, Felix Leborgne, Deborah Hall, Teresa McCloud, she was tenacious in her efforts to give me as much of a chance in
John Pile-Spellman, William Chilcote, Arlene Libby, Gus life as possible. With an incredible work ethic and her silently per-
Magrinat, Matthew Manning, Robert Murray, Peter Young, Ericka sistent and resourceful w ays, she helped mak e dreams a reality
Coates, Jerome Gehl, Minta Phillips, Randy J ackson, and Stuar t when others mocked them as foolish f antasies. Although she is no
Geller. I would also like to specifical y acknowledge two excep- longer here, her spirit lives and I continue to be guided by the strong
tional women who have been instrumental in advancing the impor- principles and work ethic she instilled in me.
tance of high-quality mammo graphy at the national and inter na- Ultimately, it w as Lisa McAllister at Lippincott Williams &
tional level, as w ell as through their outstanding courses for Wilkins who made this dream come true. I can only hope this book
technologists and physicians, Rita Heinlein and Debra Deibel. It is as useful as I believed in its need to be published. She has been
has been a privilege to work and learn with them, and I thank them incredibly supportive, gracious, and patient with me, as I struggled
for their friendship. Lastl y, I o we a special debt of g ratitude to and made requests for more figure space and time. I will for ver be
Drs. Ann S. Fulcher and Mar y Ann Turner, Chair and Vice Chair, grateful to her. Kerry Barrett and Louise Bierig ha ve been instru-
Department of Radiology, Virginia Commonwealth University, for mental to this project. Their many suggestions and meticulous work
their support and patience as I worked to complete this project. are reflected in the final product, and I thank them for the
On a personal note, I ackno wledge the suppor t of Amy Davis, commitment.
Leigh Kuhnly, Cara Sams, and Diana Shepherd, four very special Lastly, to all of the others including Nicole Walz, Ben Rivera,
women whose relentless commitment to patient care is inspira- Angela Panetta, Doug Smock, Larry Didona at Lippincott Williams
tional. They toil selfless y behind the scenes, making an incredible & Wilkins and Max Leckrone and the team at TechBooks, Inc. who
difference to so man y of us. I am also par ticularly indebted to worked behind the scenes to bring this to fruition, many thanks for
Kathleen M. Connelly, who, over the years, through many projects your hard work and dedication.
xi
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Cha p t e r 1
My Aunt Minnie
■ TERMS
Amorphous calcifications Lucent centered calcifications
Artifacts Lymph nodes
Calcified parasites Milk of calcium
Cysts Negative density artifacts
Dystrophic calcifications Nipple rings
Extracapsular implant rupture Oil cysts
Fibroadenolipomas Plus density artifacts
Gel bleed Radiolucent mass
Hair Rod-like calcifications
Hickman catheter Seborrheic keratoses
Hyalinizing fibroadenomas Skin folds
Implants Sternalis muscle
Intracapsular implant rupture Vascular calcifications
Keloids Wire fragments
Lipomas Wire localization
■ INTRODUCTION ■ FOR PATIENT DISCUSSIONS

The term “Aunt Minnie” is used in radiology to characterize lesions In approaching “patient” (as opposed to “case”) discussions,
that have a distinctive, unique appearance. Most radiology residents consider the 4 D’s. The first is detection. Is there a potential abnor-
learn about Aunt Minnie early in their careers. While planning this mality? The second is a description of a confi med finding base
book, I thought a chapter on Aunt Minnie would be easy to put on complete information (e.g., additional clinical and imaging
together. I have discovered that this is not so! At least in mammog- evaluations). Your description should lead you and the listener to a
raphy, the concept of Aunt Minnie is difficult to apply and I ha ve differential and the likely diagnosis you will propose. The third D
struggled in selecting what should be included in this chapter. Does is your differential. When considering the possibilities, remember
Aunt Minnie really always look the same? If for the same entity that all findings have benign and malignant considerations and you
there is some variation in appearance, can it still be Aunt Minnie? should move through the list in a lo gical manner. Try not to jump
Is your Aunt Minnie the same as my Aunt Minnie? back and forth from benign to malignant. Tell the listener what you
By this point you are probably wondering why I am dwelling on think the lesion could be, not what it is not. Also, try to be specific
this. Probably this is by way of a disclaimer! I have elected to illus- saying that “this is lik ely a malignanc y or cancer” is not v ery
trate entities I define as Aunt Minnie. Some of y ou may not insightful. The last D is what you think the diagnosis is most likely
recognize my Aunt Minnie; however, the entities presented are dis- to be.
tinctive and should be recognized as benign or iatrogenic. Rarely do
these require additional e valuation, short-interval follow-up, or
intervention.
1
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2 Chapter 1 • My Aunt Minnie
PATIENT 1
Figure 1.1. Screening study, 42-year-old woman: craniocaudal (A) and mediolateral oblique
(B) views.
Clinical Breast Imaging: A Patient Focused Teaching File 3
do not let benign, obviously malignant, or clinical findings distrac

What is your diagnosis?
you from reviewing the mammogram completely. You need to be
If you are not sure, what can you do to be 100% sure? even more focused in looking for potential signs of early breast can-
cer around and in between obvious findings. If there is any question
Multiple masses are projecting on the breast parench yma bilater-
about a mass being on the skin you can examine the patient and, if
ally. On close inspection, air is seen as a thin radiolucency, partially
still not sure, place a metallic BB on the identified skin lesion an
or completely outlining the margins of several of the masses (F ig.
obtain follow-up images with the BB (and skin lesion) in tangent to
1.1C, thicker arrows). Those in tangent to the x-ray beam are seen
the x-ray beam.
extending beyond the breast (Fig. 1.1C, thin arrows). Bilateral skin
BI-RADS® category 1: ne gative. BI-RADS® cate gory 2:
lesions may be seen in otherwise health y women or, when this
benign finding is used if the skin lesions are described in the bod
numerous, in women with neurofibromatosis.These patients can be
of the repor t. Next screening mammo graphy is recommended in
challenging. We are often mesmerized b y benign f indings and
1 year.
neglect more subtle findings that potentialy reflect breast cance . So,
Figure 1.1. (Continued) (C) Craniocaudal view. Skin lesions projecting be yond the skin ( thin
arrows) are easily identified. Skin lesions superimposed on the parenc yma (thick arrows) can often
be identified y a sharply defined lucen y (air) partially or completely outlining their margins.
PATIENT 2
A B
C D
Figure 1.2. A: Skin lesion, right breast, photographically coned view. The interstices of the lesion are shar ply outlined by air. A portion of the mass is
seen extending beyond the breast. B: Skin lesion, left breast, photographically coned view. Metallic BB placed on the skin lesion. A thin, sharply define
lucency (air) outlines the margins of the mass as well as some of the interstices of the lesion. Craniocaudal (C) and photographically coned (D) views of
skin lesion, laterally in the right breast. Metallic BB placed on skin lesion. The margins and interstices of the lesion are sh arply defined y a surrounding
lucency (air).
technologist uses a BB , she indicates the reason on the w oman’s

What is the diagnosis in these three patients, and how
history form and affi es a sticker on the films (e.g., “BB on mole” o
can you be certain? “BB on lump”) indicating the reason for the use of the BB . Unless
What else could you do? the skin lesions are too numerous to mark, the routine use of BBs to
mark skin lesions can avert some callbacks.
Seborrheic keratoses: Characteristic mammographic appearance is Seborrheic keratoses are common benign epidermal tumors dis-
demonstrated with these three patients. When superimposed on the tributed on skin that bears hair . They do not de velop on mucosal
breast parenchyma, skin lesions are often par tially, or completely, surfaces and are infrequent under the age of 30 y ears. They are
outlined by a thin radiolucenc y (air), as are the interstices of the common, typically multiple, and continue to de velop as patients
verrucous lesions. When they are in tangent to the x-ray beam, their age. A familial predilection with a possib le autosomal dominant
extension beyond the skin is outlined by air (radiolucent). Although form of inheritance has been described. Sebor rheic keratoses are
metallic BBs are often used to mark these skin lesions, the mam- typically flat hen they first d velop and over time can become
mographic appearance of the v errucous lesions is distincti ve. more verrucous, polypoid, and pedunculated in appearance.
Metallic BBs are more helpful on smooth skin lesions, because Rarely, rapid proliferation or increases in the size of pre-e xisting
these are more likely to simulate a breast lesion when superimposed lesions may be an indication of an inter nal malignancy (Leser-
on the breast parenchyma on the two standard views of the breast Trélat sign).
(e.g., craniocaudal and mediolateral ob lique views). When a
PATIENT 3
B
A
Figure 1.3. A: Mediolateral oblique, photographically coned view of an oval, mixed-density (fat containing) mass. B: Ultrasound image, antiradial (ARAD) pro-
jection of a hypoechoic mass with a focus of central echogenicity corresponding to the mass shown in (A) at the 2 o’clock position, 10 cm from the left nipple.
Ultrasound is used adjuncti vely in patients in w hom a l ymph

What are imaging findings of intramammary
node is suspected but a fatty hilum is not definite y seen mammo-
lymph nodes? graphically. Ultrasound is also the primar y imaging modality used
in patients who are under the age of 30 years, pregnant, or lactating,
The mammographic appearance of l ymph nodes is v ariable (Fig.
who present with a palpab le finding. On ultrasoun , lymph nodes
1.3A, C). Most commonl y, intramammary lymph nodes are w ell
are typically well-circumscribed masses with a hypoechoic cortical
circumscribed, oval (reniform), mixed-density (fat containing) masses
area and a hyperechoic central, or eccentric focus, corresponding to
localized to the upper outer quadrants. However, they can be found
the fatty hilar region seen mammographically (Fig. 1.3B, D, E, F, G,
anywhere, including the inner quadrants, and may fluctuate in siz
H). If power Doppler is used, blood fl w is seen associated with the
and density. They may have a prominent fatty component relative to
hyperechoic region.
the water-density portion or vice versa. Rarely, lymph nodes disap-
On T2-weighted magnetic resonance images, l ymph nodes
pear, only to reappear on subsequent mammograms. The mammo-
demonstrate high signal intensity . Following contrast administra-
graphic appearance of “normal” lymph nodes is usually distinctive
tion, lymph nodes are characterized b y rapid contrast uptak e on
enough that no additional imaging is indicated.
T1-weighted images. This uptake is followed by either a plateau or however, these changes are reactive and do not reflect a malignan
rapid washout. Contrast enhancement may appear rimlike when the process. Similarly, on ultrasound, biopsy is considered if there is
hilar region is centrally located (Fig. 1.3I, J). Vessels can sometimes thickening and bulging of the cor tical area, often asymmetric and
be seen in the hilar region. microlobulated, with concomitant thinning and apparent mass
Mammographically, if a l ymph node increases in size and den- effect, or complete loss, of the h yperechoic hilar region. Increased
sity and there is associated loss of the fatty hilum with indistinct or blood fl w can be seen in some of these lymph nodes.
spiculated margins, biopsy ma y be indicated; in man y women,
C D
E F
Figure 1.3. (Continued ) C: Mediolateral oblique, photographically coned vie w of a round mass with w hat may be an eccentric f atty hilum.
D: Ultrasound image, antiradial (ARAD) projection of palpable (PALP) hypoechoic mass (arrows), with an eccentric focus of echogenicity corresponding
to the mass shown in (C) at the 2 o’clock position, 4 cm from the left nipple. E: Ultrasound image, left axilla, demonstrating an oval lymph node (arrows)
characterized by a thin hypoechoic cortex and central area of echogenicity corresponding to the fatty hilum seen on mammograms. F: Ultrasound image,
left axilla, demonstrating an oval mass (arrows) with a thin hypoechoic cortex and a central oval area of echogenicity.
G H
I J
Figure 1.3. (Continued) Ultrasound images, in radial (RAD) (G) and antiradial (ARAD) (H) projections, of an oval mass (arrows) characterized by a
hypoechoic cortex and a central focus of echogenicity, at the 10 o’clock position, 10 cm from the right nipple. I: T1-weighted sagittal image, precontrast,
demonstrating a mass with a central focus of lower signal intensity. J: T1-weighted sagittal image, immediately postcontrast, at the same tabletop position
shown in (I), demonstrates rapid enhancement of the cortical rim of the mass.
PATIENT 4
A B
C D
Figure 1.4. Screening study. Craniocaudal (A) and mediolateral oblique (B) views. Diagnostic study in a different patient presenting with a
“lump” in the right breast. Craniocaudal (C) and mediolateral oblique (D) views (metallic BB marking palpable finding).
E F
Figure 1.4. (Continued) Craniocaudal (E) and mediolateral oblique (F) spot compression views of the palpable finding in the right breast
and hyperechoic areas with disruption of normal tissue architecture.

How would you describe the findings?
The posterior acoustic features of these lesions are v ariable and
include no posterior acoustic features, enhancement, shadowing, or
a combined pattern (areas of enhancement and areas of shadowing).
Mixed-density (fat containing) masses are imaged mammo graphi-
Variable combinations of adipose tissue, fibrous stroma, and lob
cally in these two patients consistent with fibroadenolipomas (als
ular structures are seen histologically and, although separable from
called hamartoma, breast-within-a-breast). F atty, glandular and
the adjacent breast tissue, hamar tomas lack a true capsule. Rarely,
fibrous tissues are surrounded, and separated, from the remainder of
myxoid and chondroid hamar tomas are repor ted histologically
the breast tissue by a fibrous pseudocapsule. As illustrated by these
when the lesions contain muscle and cartilage, respectively. A myx-
two patients, the proportions of each tissue type v ary from patient
oid hamartoma has been reported in a 36-year-old male presenting
to patient. In some w omen the lesions are mostl y fatty, in others
with a slo wly growing breast mass. Breast cancer can arise in
glandular tissue predominates. They can be detected on screening
fibroadenolipomas, so the tissue in these lesions should be e valu-
studies (Fig. 1.4A, B, left breast) or, in some patients can present as
ated for the development of any mass, distortion, or calcification
a palpable finding ( ig. 1.4C, D, right breast). Rarely, they occur in
as thoroughly as breast tissue anywhere else.
accessory axillary glandular tissue and may enlarge rapidly.
BI-RADS® category 2: benign finding. N xt screening mammo-
On ultrasound, fibroadenolipomas are usual y separable from sur-
gram is recommended in 1 year.
rounding normal tissue and characterized by an admixture of hypo-
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PATIENT 5
A B
C D
E F
Figure 1.5. Screening study. Craniocaudal (A) view exaggerated laterally and mediolateral oblique (B) view, photographically coned. Screening study,
different patient. Craniocaudal (C) and mediolateral oblique (D) views, photographically coned. Ultrasound images in radial (E) and antiradial (ARAD)
(F) projections of a palpable mass at the 6 o’clock position, 2 cm from the left nipple, radiolucent on the mammogram (not shown).
lipomas can be slightly hyperechoic and a small amount of poste-

rior acoustic enhancement ma y be noted (F ig. 1.5E, F). A gentle
What is your diagnosis? mass effect on surrounding tissue and Cooper ligaments can also be
seen with some lipomas. Rarel y, lipomas can be seen within the
Radiolucent, well-circumscribed masses (small arrows) with a thin
pectoral muscle.
fibrous capsule consistent with lipomas; these rarely calcify. Unlike
BI-RADS® category 2: benign finding. N xt screening mam-
oil cysts, which have a variable sonographic appearance but often
mography is recommended in 1 year.
simulate cysts, lipomas are well circumscribed, solid, slightly hypo-
or isoechoic masses on ultrasound (large arrows). In some women,
PATIENT 6
Figure 1.6. Diagnostic study in a 60-year-old patient present-

ing with a “lump” in her right breast. Spot tangential (A) view of
A the “lump” with a metallic BB placed at the site of concern. The
patient has had a reduction mammoplasty.
B
C
Figure 1.6. Ultrasound images, radial (RAD) (B) and antiradial (ARAD) (C) projections of palpable finding, right breast.
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BI-RADS® category 2: benign finding. ext screening mam-

H ow would you describe the findings?
mography is recommended in 1 year.
On physical examination, there is a discrete, hard, lobulated mass
palpated at the 12 o’clock position, 1 cm from the right nipple. A
Two adjacent 5 -mm round, well-circumscribed radiolucent masses macrolobulated, nearly anechoic mass with significant shadowing
are seen mammographically, corresponding to the “lump” described is imaged, corresponding to the palpab le finding. Although the
by the patient. Given the history of a reduction mammoplasty, these ultrasound is included for illustrati ve purposes, the diagnosis is
are consistent with oil c ysts. The diagnosis is estab lished mammo- made on the mammo graphic findings (i.e., ultrasound is not indi
graphically. Radiolucent masses in the breast are benign. The benign cated when a radiolucent mass is seen mammo graphically). Oil
nature of the palpable finding is discussed with the patient, and she i cysts can have a variable appearance on ultrasound, ranging from
reassured that this is not breast cancer and that it will not become simulating a simple c yst to a comple x cystic mass or a mass with
cancerous. A definit ve report is issued to avoid unnecessary surgery. significant shad wing as seen here.
PATIENT 7
Figure 1.7. Screening study, 49-year-old woman. Craniocaudal (A) view.

Figure 1.7. (Continued) Mediolateral oblique view.
C D
Figure 1.7. (Continued) Craniocaudal (C) and mediolateral oblique (D) views, photographically coned, left breast.
Steatocystoma multiplex is a rare, autosomal dominant condition

characterized by the presence of multiple cutaneous c ysts appear-
ing during adolescence and increasing pro gressively with age
These are oil cysts with eggshell or rim calcification. Oil ysts com-
involving the anterior trunk, back, proximal extremities, and exter-
monly develop following trauma or surgery; however, most patients
nal genitalia. Multiple oil cysts are seen mammographically.
do not recall the trauma (and ma y not recall sur gery). These are
BI-RADS® category 1: negative. BI-RADS® category 2: benign
round or o val, well-circumscribed, radiolucent masses. As illus-
finding is used if the findings are described in the body of th
trated here, thin calcifications can d velop in the w all of the c yst.
report. Next screening mammogram is recommended in 1 year.
With time these ma y stabilize or decrease pro gressively in size
(Fig. 1.7E, F) and, in some patients, eventually resolve completely.
E F
Figure 1.7. (Continued) Screening study, 46-year-old woman. Photographically coned images (E, F) of same area in the right breast, 2 years apart.
PATIENT 8
Figure 1.8. Screening study, 63-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast.
C Figure 1.8. (Continued) Mediolateral oblique (C) view, left breast, pho-
tographically coned.
Figure 1.8. (Continued) Screening study, 40-year-old woman. Craniocaudal (D) views.
16
Figure 1.8. (Continued) Craniocaudal (E) views, 1 year following (D). Craniocaudal (F) view, left breast, photographically
coned.
Figure 1.8. (Continued) Craniocaudal (G) view, left breast, photographically coned, 1 year following (F).
lishing a change in overall breast size following the surgery, as well

as the development of the oil cysts.
What procedure have both of these patients
undergone?
What are the imaging findings associated with fat
A radiolucent mass with mural and inter nal curvilinear calcifica necrosis?
tions is seen in the left breast in F ig. 1.8A–C. The appearance of
some of the internal calcifications suggests the presence of smalle In the acute setting, fat necrosis following reduction mammoplasty
lucent masses within the dominant mass. Also noted is asymmetric may present with one or multiple, mixed-density masses; some may
tissue inferiorly on the right mediolateral oblique view demonstrat- be spiculated. As the inflammato y process associated with f at
ing a swirling pattern (Fig. 1.8B). The left breast is smaller than the necrosis resolves, single or multiple, uni- or bilateral oil c ysts of
right. The findings suggest a histo y of reduction mammoplasty , varying sizes may remain. Although some may develop rim calcifi
which is confi med on the patient’s history sheet. cations, most develop coarser, curvilinear calcifications, as demon
In the second patient, multiple mix ed-density masses of varying strated in these tw o patients. With time, these ma y stabilize, con-
sizes are present bilaterally (Fig. 1.8D). A few dense calcification tinue to calcify, or some e ventually resolve completely. In some
are associated with some of the masses (F ig. 1.8D, F). A year later, patients, these become palpable as they calcify 1 or 2 years follow-
many more coarse calcifications are noted associated with th ing the surgery. When they are palpable, it is important to reassure
mixed-density (fat containing) masses (Fig. 1.8E). The calcification the patient that the palpab le finding is benign and requires no fur
are now more curvilinear in appearance, seemingly outlining a clus- ther intervention. It is also impor tant that a definit ve report be
ter of lucent masses (Fig. 1.8G). As the calcifications h ve increased, issued.
the overall size and associated soft tissue component of some of the BI-RADS® category 1: negative. BI-RADS® category 2: benign
masses has decreased. The presence of multiple, bilateral oil c ysts finding is used if the findings are described in the body of th
may reflect a histo y of trauma or, as in this patient, reduction mam- report. Next screening mammogram is recommended in 1 year.
moplasty. Comparison films, if vailable, will be helpful in estab-
PATIENT 9
A B
decrease in size, an increase in density, and the development of dense,

What is the diagnosis and what BI-RADS® category
dystrophic calcifications in a pre- xisting well-circumscribed mass.
would you assign?
Because these calcifications d velop in hyalinized fibrous tissue, th y
are variable in size, shape, and density (i.e., there is no prefor med
Multiple, well-circumscribed, dense masses, some with macrolobula-
space molding the de veloping calcifications). Also noted is a w ell-
tions and varying amounts of associated dense, coarse calcifications
circumscribed, mixed-density oval mass superimposed on the pectoral
are present in the left breast. These are h yalinizing fibroadenoma
muscle on the mediolateral ob lique view, consistent with a l ymph
with associated dystrophic calcifications (i.e., popco n-type calcifica
node.
tions). As estrogen levels decrease, the epithelial component in
fibroadenomas atrophies and is replaced by dense, hyalinized fibrou
tissue. These changes may be characterized mammographically by a
PATIENT 10
B
Figure 1.10. Screening study, 65-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast, pho-
tographically coned.
tion (Fig. 1.10C arrowheads) are incidentally noted. These are all
What observations can you make, and do you think
hyalinizing fibroadenomas. It is impo tant to recognize that a mass
this woman needs to be called back for additional
is not always seen in association with the dystrophic calcification
evaluation? of a fibroadenoma (i.e., a cluster of calcifications alone can repr
sent a hyalinizing fibroadenoma). These findings require no addi
Two macrolobulated, dense masses with par tially well circum- tional evaluation or shor t-interval follow-up. However, don’t be
scribed margins and coarse, dense calcifications are imaged in th lulled by obviously benign findings; ma e sure to focus your atten-
left breast. A cluster of dense, tightl y packed calcifications i tion on the remainder of the mammogram.
also present (Fig. 1.10C, ar row), with no associated soft tissue
component. Scattered benign calcifications and a terial calcifica
Figure 1.10. (Continued) Craniocaudal (C) view, left breast. Macrolobulated masses with dense, coarse calcifications represent yalini-
zing fibroadenomas. Although no soft tissue component is present, a cluster of dense tightly packed calcifications (a row) also represents a
hyalinizing fibroadenoma. Arterial calcification (a rowheads) is present.
PATIENT 11
A B
C D
Figure 1.11. Screening studies, 43-year-old woman. Mediolateral oblique (A) view left breast, photographically coned. Mediolateral oblique (B) view,
left breast, 1 y ear after (A), photographically coned. Mediolateral ob lique (C) view, left breast, 3 y ears after (A), photographically coned. Mediolateral
oblique (D) view, left breast, 5 years after (A), photographically coned.
decreases slightly in size, becomes denser , and the calcification

increase in number, size, and density. These findings are diagnosti
of a hyalinizing fibroadenoma with dystrophic calcifications (i.e
An oval mass, with partially obscured and well-circumscribed mar-
developing popcorn calcification). This finding is benign an
gins and associated dense coarse calcifications, is imaged anterio
requires no additional evaluation or short-interval follow-up.
to the pectoral muscle. On subsequent screening studies, the mass
PATIENT 12
Figure 1.12. Diagnostic study, 48-year-old patient presenting with a “lump” in the left breast. Mediolateral
oblique (A) views with metallic BB on the “lump” described by the patient in the left breast.
B C
D E
Figure 1.12. (Continued) Spot compression (B) view of palpable finding. Left subareolar area (C), 5 years before (A, B), photographically coned view.
Ultrasound images, radial (RAD) (D) and antiradial (ARAD). (E) projections of palpable (PALP) finding.
cally. The mammographic findings are diagnostic of a yalinizing

How would you describe the mammographic and
fibroadenoma with associated dystrophic calcifications. Although
ultrasound findings, and what is your recommendation
an ultrasound is sho wn here for completeness, the diagnosis is
for this patient? made on the mammo graphic findings. This is e xplained to the
patient; she is reassured that w hat she feels is a benign lesion that
Lymph nodes are present in both axillar y regions. A 2-cm mass will not turn into cancer and has been present for 5 y ears with no
with obscured margins and associated coarse calcifications is see significant changes. A definit ve report is issued describing the
in the left subareolar area on the mediolateral oblique views. On the palpable finding as a yalinizing fibroadenoma requiring no fu ther
spot compression vie w, the mar gins are ir regular and indistinct. intervention or short-interval follow-up.
Compared with the study from 5 years previously, the mass is now As the estro gen levels decrease, the epithelial elements in
more dense and the calcifications are la ger. fibroadenomas atrophy and are replaced by an increasing amount of
On physical examination, a readily mobile, hard, nontender mass fibrous tissue. Mammographically, hyalinizing fibroadenomas m y
is palpated at the 11:30 o’clock position, 2 cm from the left nipple. decrease slightly in size and become more dense so that, in some
On ultrasound, a round mass with hetero geneous echotexture and women, they become more readil y apparent while some undergo
shadowing is imaged corresponding to the palpable finding. S veral calcification, as demonstrated in this patient.
areas of hyperechogenicity (Fig. 1.12F, G, arrows), some curvilin- BI-RADS® category 2: benign finding. N xt screening mammo-
ear, others with associated shadowing (Fig. 1.12F, G, arrowheads), gram is recommended in 1 year.
are noted consistent with the calcifications seen mamm graphi-
F G
Figure 1.12. Ultrasound images, radial (RAD) (F) and antiradial (ARAD) (G) projections of palpable (PALP) finding in the left breast at the 11:30 o’cloc
position, 2 cm from the nipple. A round, hypoechoic mass with heterogeneous echotexture, dense calcifications arrows), and shadowing are imaged, corre-
sponding to the palpable area of concern to the patient. Shadowing (arrowheads) is intermittently seen associated with some of the calcifications
PATIENT 13
A B
Figure 1.13. Screening mammogram, 63-year-old woman. Craniocaudal (A) view, left breast. Craniocaudal (B) view, left breast, 3 years previously.
patients (i.e., those on oral antihypertensives) compared to women

with no history of diabetes or hypertension.
Arterial calcifications in oung women, particularly when in
Linear, parallel, tram-track-lik e calcifications represent ascular
conjunction with skin thick ening (specifical y axillary skin) and
(arterial) calcifications. This patient has de veloped dense vascular
breast microcalcifications, h ve also been reported in women with
calcifications in the span of 3 y ears, suggesting the possibility of
pseudoxanthoma elasticum (PXE). This is an autosomal recessi ve
diabetes or atherosclerotic disease that ma y be significant. In thi
disorder characterized by fragmentation, clumping, and calcifica
patient, I describe the development of vascular calcifications in th
tion of elastic fibers in skin, yes, and ar teries. Yellowish skin
mammographic report. It is reasonab le to contact the refer ring
papules and redundant skin folds at fl xural sites (e.g., axilla, groin)
physician directly, particularly if the patient pro vides no informa-
are common cutaneous findings.Angioid streaks in the retina affect
tion relative to underlying diabetic, cardiac, or renal disease (e.g.,
almost 100% of patients after the age of 30 y ears and can result in
what medications is the patient taking?), to discuss the findings
loss of visual acuity. Peripheral vascular disease, resulting from cal-
Reportedly, arterial calcifications are more common in post
cification of medium-sized arteries, can lead to claudication, hyper-
menopausal women who are not on hor mone replacement therapy
tension, angina, myocardial infarction, cerebrovascular accidents,
(HRT). The rapid de velopment of ar terial calcifications in som
bowel angina with resulting gastrointestinal b leeding, and compli-
perimenopausal women might serve as an indication for consider-
cated pregnancies, often resulting in miscar riages. Although skin
ing HRT; also, mammography may prove helpful in monitoring the
changes commonly develop during childhood, the disorder is not
effectiveness of HR T. The prevalence of ar terial calcification
usually diagnosed until the third or four th decade, when systemic
increases with age among all w omen. However, it is impor tant to
complications become apparent.
recognize that arterial calcifications are repo tedly four times more
likely in diabetic patients (i.e., those on insulin or oral h ypo-
glycemic agents) and three times more lik ely in h ypertensive
PATIENT 14
A B
Figure 1.14. Screening mammogram, 55-year-old woman. Mediolateral oblique (A) view, right breast. Mediolateral ob lique (B) view, right breast,
4 years previously.
patients (i.e., those on oral antihypertensives) compared to women

with no history of diabetes or hypertension.
Arterial calcifications in oung women, particularly when in con-
Dense, linear, parallel, tram-track-like calcifications represent as-
junction with skin thick ening (specifical y axillary skin) and breast
cular (arterial) calcification. In this patient, the a terial calcificatio
microcalcifications, have also been reported in women with pseudox-
is resolving. Typically, vascular calcifications d velop and can be
anthoma elasticum (PXE). This is an autosomal recessi ve disorder
seen mammographically as w omen age. As illustrated b y this
characterized by fragmentation, clumping and calcification of elasti
patient, if the underlying cause(s) of atherosclerosis is (are) treated
fibers in skin, eyes, and arteries. Yellowish skin papules and redundant
successfully, vascular calcifications can resol e partially or com-
skin folds at fl xural sites (e.g., axilla, groin) are common cutaneous
pletely, but this is the rare case.
findings. Angioid streaks in the retina affect almost 100% of patients
Reportedly, arterial calcifications are more common in post
after the age of 30 y ears and can result in loss of visual acuity .
menopausal women who are not on hor mone replacement therapy
Peripheral vascular disease, resulting from calcification of medium
(HRT). The rapid de velopment of ar terial calcifications in som
sized arteries, can lead to claudication, hypertension, angina, myocar-
perimenopausal women might serve as an indication for consider-
dial infarction, cerebrovascular accidents, bowel angina with resulting
ing HRT; also, mammography may prove helpful in monitoring the
gastrointestinal bleeding, and complicated pre gnancies, often result-
effectiveness of HR T. The prevalence of ar terial calcification
ing in miscarriages. Although skin changes commonly develop during
increases with age among all w omen. However, it is impor tant to
childhood, the disorder is not usuall y diagnosed until the third or
recognize that arterial calcifications are repo tedly four times more
fourth decade, when systemic complications become apparent.
likely in diabetic patients (i.e., those on insulin or oral h ypo-
glycemic agents) and three times more lik ely in h ypertensive
PATIENT 15
Figure 1.15. (Continued) Screening study, 80-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.
D E
Figure 1.15. (Continued) Craniocaudal (C) views, screening study 5 y ears prior to (A, B). Screening study, 76-year-old woman. Craniocaudal (D)
view, right breast. Craniocaudal (E) view, right breast, 2 years prior to (D).
Progressive development of large rodlike calcifications is note

How would you describe the findings, and what would
in the right craniocaudal vie ws shown in F ig. 1.15D. These are
you recommend next?
benign and require no additional e valuation or inter vention. Also
noted is vascular calcification. Annual screening mammography is
Large rodlike calcifications are present bilateral y (Fig. 1.15A, B).
recommended for these two patients. However, a word of caution is
These calcifications are typical y coarse, dense, and rod shaped. As
indicated when large rodlike calcifications d velop focally in a
demonstrated, they develop progressively (compare F ig. 1.15A
patient, particularly if the calcifications are not oriented t ward the
with Fig. 1.15C), are often oriented to ward the nipple, and the
nipple and there are no other calcifications in either breast. Rare y,
process is commonly bilaterally. Branching may be seen, and when
ductal carcinoma in situ (DCIS) with central necrosis can present
the calcifications d velop periductally, a central lucenc y may be
with calcifications that m y be mistaken for the type of calcificatio
noted. These calcifications h ve been described as being associated
illustrated here.
with duct ectasia; a variety of terms have been used to describe the
process, including periductal mastitis, secretor y disease, comedo
finding is used if the calcifications are described in the body of th
mastitis, plasma cell mastitis, and mastitis obliterans. Also noted is
the progressive development of arterial calcifications
PATIENT 16
Figure 1.16. Screening study, 42-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.
D
Figure 1.16. (Continued) Digital screening study, 40 year-old woman. Craniocaudal (C) and mediolateral oblique
(D) views of the left breast, photographically coned.
E G
H I
Figure 1.16. (Continued) Ultrasound image (E) in the radial (RAD) projection at the 2 o’clock position, 1 cm from the left nipple. Screening study, 72-year-
old woman. Craniocaudal (G) and mediolateral oblique (H) views, photographically coned. Ultrasound Image (I) at the 10 o’clock position, 2 cm from the left
nipple.
the dependent portion of the cyst, corresponding to some of the lay-

For each mammogram shown, describe the findings.
ering calcifications identified mam graphically (Fig. 1.16F).
What is the diagnosis in all three patients, and is a
A cluster of round and o val calcifications is imaged in the righ
biopsy or short-interval follow-up indicated for any of craniocaudal view (Fig. 1.16G). The calcifications shift in positio
these patients? and their overall distribution suggests that they are contained within
a nonvisualized round mass on the mediolateral oblique view (Fig.
Amorphous calcifications of arying size and shapes are dif fusely 1.16H). On ultrasound (F ig. 1.16I), a c yst is imaged at the 10
scattered throughout the dense parenchyma on the craniocaudal o’clock position of the right breast, 2 cm from the nipple, the
views (Fig. 1.16A). On the mediolateral oblique views, the calcifi expected location of the calcifications seen mamm graphically.
cations are well define , higher in density compared to the cranio- Discrete echogenic foci (Fig 1.16J, arrows) and an irregular curvi-
caudal view, and most demonstrate a cur vilinear or linear appear- linear focus of echogenicity (Fig 1.16J, arrowheads) are imaged in
ance (Fig. 1.16B). the cyst, reflecting the calcifications seen mam graphically (Fig.
A cluster of amorphous calcifications is seen lateral y in the left 1.16J). As expected, the calcifications are contained in a yst.
breast on the craniocaudal view (Fig. 1.16C). The individual calci- These three patients demonstrate the variable appearance of milk
fications are better define , denser, and demonstrate a more linear of calcium. The diagnosis is established on the mammographic fea-
appearance on the mediolateral ob lique view (Fig. 1.16D). On tures of the calcifications. This reflects calcium in suspensio
ultrasound (Fig. 1.16E), a cluster of subcentimeter cysts is imaged within microcysts, less commonly in macrocysts. Amorphous cal-
at the 2 o’clock position, 1 cm from the nipple (onl y one of which cifications are seen on the craniocaudal vie w. On mediolateral
is shown), corresponding to the area of the clustered calcification oblique and 90-de gree lateral vie ws, the calcium la yers creating
seen mammographically. Discrete echogenic foci (Fig 1.16F, arrows) sharply define , curvilinear calcifications (“teacups”). The charac-
and a linear area of echogenicity (Fig 1.16F, arrowheads) are noted in teristic mammographic feature of this type of calcification, there
fore, is a dif ferential appearance betw een craniocaudal and 90- sion that can be seen changing appearances betw een craniocaudal
degree lateral views, although it can also be seen on mediolateral and mediolateral ob lique or 90-de gree lateral vie ws. If an ultra-
oblique views in many patients. If the diagnosis is in question on sound is done, cystic changes, some with associated calcifications
the screening study, the patient is called back to confi m the diag- are often identifia le.
nosis with a 90-degree lateral view. This process can be diffuse and BI-RADS® category 1: ne gative. BI-RADS® cate gory 2:
bilateral, unilateral or focal. Although it is most common for the benign finding is used if the calcifications are described in the bo
calcium to be in suspension, in some patients there are indi vidual of the repor t. Next screening mammogram is recommended in 1
calcifications (often with some what geometric shapes) in suspen- year.
F J
Figure 1.16. (Continued) Ultrasound image (F) in the radial (RAD) projection at the 2 o’clock position, 1 cm from the left nipple. One of se veral sub-
centimeter cysts in the upper outer quadrant of the left breast. Echo genic foci (arrows) and a linear focus of echo genicity (arrowheads) are noted in the
dependent portion of the cyst. This is milk of calcium. (J) Ultrasound image (J) at the 10 o’clock position, 2 cm from the left nipple. A cyst with calcifica
tions (arrows) and a curvilinear focus of echogenicity consistent with calcium out of suspension in the dependent portion of the cyst (arrowheads).
PATIENT 17
A B
Figure 1.17. Screening study, 67-year-old patient. Craniocaudal (A) view, right breast. Craniocaudal (B) view, right breast,
2 years after (A).
How would you describe the findings, and what is your

diagnosis?
This patient illustrates the pro gressive development of dystrophic

calcifications. These calcifications d velop in stromal fibrous tissu
and not in predefined anatomic spaces or st uctures (e.g., acini,
ducts, or v asculature). Consequently, they are v ariable in size,
shape, and density. When diffuse and bilateral, they can reflect th
presence of an underl ying metabolic (e.g., renal f ailure, hyper-
parathyroidism), inflammato y, or de generative process. When
focal, they can be associated with hyalinizing fibroadenomas, scle
rosed papillomas, or f at necrosis (posttrauma, postsur gical). In
most women, no etiology is identified
finding, is used if the calcifications are described in the body of th
Figure 1.17. (Continued) Craniocaudal (C) view, right

breast, 4 years after (A).
PATIENT 18
A B
Figure 1.18. Screening study, 72-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, photographically coned.
and require no additional e valuation, short-interval follow-up, or

What is the most likely diagnosis?
intervention.
A focus of coarse, dystrophic calcifications is noted in this patients
finding is used if the calcifications are described in the body of th
mammogram. Although no mass is seen, these most likely reflect
hyalinized fibroadenoma. The bottom line is that these are benign
PATIENT 19
Figure 1.19. Screening study, 53-year-old woman. Craniocaudal views, photographically coned.
calcifications in a common location and require no additional

How would you describe the findings, and do you think
evaluation. Regardless of size, lucent-centered calcifications ar
additional evaluation is indicated?
benign.
BI-RADS® category 1: negative. Next screening mammogram
Clusters of round and o val, lucent-centered calcifications ar
is recommended in 1 year.
imaged in the posteromedial aspect of the breasts. These are skin
PATIENT 20
Figure 1.20. Screening study, 54-year-old woman. Mediolateral oblique views, photographically coned.
imaged on mammo grams or ultrasound. On magnetic resonance

What is your impression?
images, gel bleed is characterized by the filling of wrinkles (“ ey-
hole”) present in otherwise intact implants. This is in contrast with
Silicone implants are present in a subglandular location. A triangu-
the extravasation of silicone resulting from a disr uption of the
lar density is imaged, extending superiorly from the right implant
implant shell.
along the anterior edge of the pectoral muscle. This is consistent
with silicone and an e xtracapsular implant r upture. Extravasated
silicone is noted as a high-density material that can assume a v ari- What types of implant ruptures are there, and how are
ety of shapes and sizes. In some w omen, silicone is seen as round they diagnosed?
high-density masses or triangular globs in the breast, w hereas in
others it is within the lymphatic system extending into the axilla. After an implant is placed in the body , a fibrous capsule fo ms
around the implant. If rupture of the implant shell occurs and there
What is gel bleed? is an intact “nati ve” fibrous capsule, the xtravasated silicone is
contained by the capsule (i.e., intracapsular implant r upture). This
Relative to silicone implants, consider three different concepts: gel type of implant rupture is not apparent on a mammogram; it may be
bleed, intracapsular implant rupture, and extracapsular implant rup- identified on ultrasound and it is easil y diagnosed with magnetic
ture. Gel bleed is a natural phenomenon associated with silicone resonance imaging (MRI). If the patient’s own capsule is disrupted,
implants. The implant shell, made of silicone, is a semiper meable rupture of the implant can result in e xtracapsular extension of the
membrane that allows for the egress or bleed of silicone naturally. extravasated silicone. This type of rupture can be diagnosed mam-
This bleed may be low or high grade, depending on the amount of mographically, on ultrasound, and with MRI.
cross-linking of the silicone elastomere shell. Gel b leed is not
PATIENT 21
Figure 1.21. Screening study, 40-year-old woman.

Craniocaudal (A) views, photographically coned.
B Craniocaudal (B) view, right breast medially, photographic
cone down.
Figure 1.21. (Continued) Implant displaced views (C), craniocaudal projection.
on the implant-displaced view (Fig. 1.21C). This finding is consis

tent with extracapsular implant rupture.
Round, high-density globules of silicone are imaged at the edge of
the silicone implant, medially on the right. These are better imaged
PATIENT 22
A B
of opacity in the craniocaudal view is consistent with partial (nearly

complete) collapse of a saline implant.
Saline implants are present in a subglandular location. The signifi
cant folding of the implant on the oblique view and the relative lack
PATIENT 23
Figure 1.23. Diagnostic study, 57-year-

old patient presenting with a “lump” in the
upper outer quadrant of the right breast.
Craniocaudal (A) views, photographically
B coned laterally. Craniocaudal (B) view, right
breast, photographically coned medially.
C D
Figure 1.23. (Continued) Ultrasound image (C), radial (RAD) projection at the site of the palpable (PALP) finding, 10 o’clock position, 12 cm from th
right nipple. Ultrasound image (D), antiradial (ARAD) projection at the site of the palpab le (PALP) finding, 10 o’clock position, 12 cm from the righ
nipple.
imaged at the site of the palpable abnormality, 10 o’clock position,

How would you describe the imaging findings, and
right breast, 12 cm from the nipple. The “snowstorm” appearance
what is your diagnosis?
of extravasated silicone is also demonstrated in some of the images
obtained during the ultrasound study (F ig. 1.23D); an ir regular
High-density globules adjacent to the right implant (ar rows, Fig.
curvilinear echogenic focus is imaged, characterized by shadowing
1.23E, F) are diagnostic of an e xtracapsular implant r upture. On
associated with high specular echoes.
ultrasound, round and ir regular hypoechoic masses (ar rows, Fig.
1.23G), some with angular mar gins and an echo genic halo, are
Figure 1.23. (Continued) Craniocaudal (E) views, photographically coned laterally. Extravasated silicone is present (arrows) closely apposed to the right
implant posterolaterally.
F G
Figure 1.23. (Continued) Craniocaudal (F) view, right breast, photographically coned medially. Extravasated silicone is present (arrows) closely apposed to
the right implant medially. Also noted is calcification of the capsule arrowheads). Ultrasound image (G), radial (RAD) projection at the site of the palpab le
(PALP) finding, 10 o’clock position, 12 cm from the right nipple.The appearance of silicone on ultrasound is variable. In this image, extravasated silicone is
imaged as a cluster of round and irregular hypoechoic masses.
PATIENT 24
Figure 1.24. A: Craniocaudal views, photographically coned view medially. B: Craniocaudal views, photographically coned view
medially.
unsharpness). Although hair may be superimposed on an y image

What is the pertinent observation?
and in any posterior location, it is most commonly seen posterome-
dially on craniocaudal views. The technologist needs to make sure
Swirls of hair are seen on one (F ig. 1.24A, right) and both (F ig.
that all the patient’s hair is pulled back. Repeat views may be indi-
1.24B) craniocaudal views posteromedially. As the patient is posi-
cated if a potential lesion could be obscured. In the e xamples pre-
tioned for the craniocaudal view she is asked to turn her head away
sented, the right craniocaudal (F ig. 1.24A) needs to be repeated
from the breast being imaged. As this is done, hair can come down
because the density of the superimposed hair may obscure a cluster
along the neck and project on the breast. Because the hair is a dis-
of calcifications or a small spiculated mass
tance from the cassette, the s wirls are not shar p (geometric
PATIENT 25
A B
Figure 1.25. Right (A) and left (B) craniocaudal views, photographically coned anteriorly.
This is zinc o xide ointment (Desitin) on the skin. If there is an y

question that this may represent calcifications, the patient is as ed
What is your working hypothesis, and how can it be
if she applied something to her skin; she can be e xamined and
tested? asked to wipe her breast clean before follo w-up films are ta en to
confi m partial or complete removal of the ar tifact. Note the pres-
High-density material with linear (w avy) and punctate for ms ence of bilateral arterial calcification
involving the anterior aspect of the breasts represents an ar tifact.
PATIENT 26
Figure 1.26. A: Craniocaudal

views, photographically coned
medially. B: Different patient.
B Mediolateral oblique view, photo-
graphically coned superiorly.
Hickman central venous catheters. These are typically found in the

What is demonstrated in these two patients?
upper inner quadrants of either the right or left breast. Although
rare, abscess for mation around the cuf f has been repor ted and
A high-density, tubular structure is imaged posteromedially in the
should be suspected if an irregular mass that may contain air is seen
left breast (Fig. 1.26A). Similarly, a tubular str ucture with dense
associated with the cuff.
edges is seen superimposed on the left pectoral muscle in a dif fer-
ent patient (F ig. 1.26B). These are retained Dacron cuf fs from
PATIENT 27
A B
C D
Figure 1.27. Screening study, 62-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left
breast, photographically coned. Craniocaudal (C) and mediolateral oblique (D) views, 1 year after (A) and (B),
photographically coned.
excision of the wire fragments, as well as the wire used for the cur-
rent localization procedure.
What recommendation would you make based on the
Specimen radiography is indicated follo wing all preoperati ve
most recent set of images? wire localizations for several reasons, including documentation that
the localized lesion and localization wire ha ve been excised. The
A retained wire fragment is imaged in the upper inner quadrant of radiograph is also used to mark the location of the lesion of interest
the left breast, consistent with the history provided by the patient of for the pathologist. Rarely, additional unsuspected lesions ma y be
a breast biopsy preceded b y wire localization “man y” years ago identified on the specimen radiograph, and proximity of the lesion
(Fig. 1.27A, B). The wire fragment is stable in appearance and posi- to the margins may be suggested. However, it is important to recog-
tion compared with several prior mammograms, and the patient is nize that the radio graph is a tw o-dimensional representation of a
asymptomatic. On her ne xt screening mammo gram (Fig. 1.27C, three-dimensional structure and therefore the status of the margins
D), the wire is fragmented and the lar ger of the two fragments has requires histologic evaluation. The surgeon is contacted following a
migrated such that it ma y be embedded in the pectoral muscle; review of the specimen radiograph. If the localizing wire is not seen
however, this cannot be confi med because the wire could not be on the specimen radio graph, the surgeon is asked if it w as pulled
imaged in its entirety on the craniocaudal view. Given the changes during the surgical procedure. If the sur geon is unable to provide
noted in the wire, e xcisional biopsy follo wing preoperative wire reassurance about the location of the wire, a follo w-up mammo-
localization of the fragments is recommended. A specimen radi- gram is obtained 6 to 8 weeks following the surgery.
ograph obtained follo wing the sur gical procedure documents
PATIENT 28
A B
C D
Figure 1.28. Screening study, 88-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, photographically coned views, right breast.
Craniocaudal (C) and mediolateral oblique (D) views, photographically coned, right breast, screening study 8 years prior to (A) and (B).
limited to, needle tips, sewing needles, lead pencil tips, bullets, bul-
What do you think, and what are the possible
let fragments, and buckshot. Patients are usually asymptomatic and
explanations?
unaware of the presence of a foreign body in their breast. Iatrogenic
sources of foreign bodies include acupuncture needles, sur gical
A needle tip is present in the subcutaneous tissue. A biopsy marker
clips following lumpectomy and axillary dissection, retained wire
is seen at this site on films done 8 ears ago; its association with the
fragments following preoperative wire localizations, metallic
needle tip on both images suggests the possibility that the needle tip
markers placed to mark the site of a prior percutaneous needle
is retained from a breast surgical procedure the patient had 30 years
biopsy, port-a-catheters, pacemakers, and retained Dacron cuf fs
previously. Alternatively, the location of the needle tip at a prior
from a Hickman catheter.
biopsy site ma y be coincidental and not related to the sur gery.
Foreign bodies that can be seen in the breast include, but are not
PATIENT 29
Figure 1.29. Screening study. Craniocaudal views.
position and lift the breast up from the inframammary fold as much
What do you think of these images?
as the natural mobility of the breast will allo w. After lifting the
Why are the pectoral muscles sharply outlined by
breast, it is important to pull the breast out away from the chest wall
radiolucency? and to tug on the lateral aspect of the breast as much as the natural
mobility of the breast allows. As the breast is lifted, a skin fold can
The images are of fairly good quality, in that exposure and contrast are be created inferiorly if a por tion of abdominal w all skin is lifted
optimal; however, there are lar ge skin folds inferiorl y (at inframam- with the breast. Since this fold develops inferiorly, the technologist
mary fold (IMF)/abdomen) simulating pectoral muscles.Air outlining is unable to see it as she inspects the breast superiorl y before the
the skin folds accounts for the radiolucency noted at the anterior edge exposure is made. As in this patient, when this skin fold develops,
of the folds. The tissue surrounding the skin folds should be evaluated it can simulate the pectoral muscle. Unlik e the pectoral muscle, a
carefully for blurring, because the skin folds may limit compression. sharp radiolucency (air) is seen abutting the skin fold.
In positioning the breast for the craniocaudal projection, the
technologist should identify the inframammar y fold at its neutral
PATIENT 30
Figure 1.30. Screening studies. Mediolateral oblique views.
pectoral muscle. The breast and underl ying pectoral muscle are
What do you think?
then mobilized medially as much as possible. If care is not taken, a
Are these optimally positioned mediolateral oblique
skin fold can develop laterally as the breast is mobilized mediall y.
views? If the technolo gist looks at the medial aspect of the breast after
compression is applied, she is unable to see the skin fold because it
The pectoral muscles are wide at the axilla. The anterior margin is is up against the buck y and therefore is not apparent. The edge of
slightly concave, but the muscles reach the le vel of the nipples. the fold is outlined b y air so a thin radiolucenc y is noted abutting
There are, however, large skin folds superimposed on the pectoral the skin fold. A lymph node is incidentally noted, superimposed on
muscles posteriorly. the right pectoral muscle.
In positioning the breast for the mediolateral oblique projection,
the angle of ob liquity is deter mined by the orientation of the
PATIENT 3 1
Figure 1.31. Screening study, 47-year-old woman. Craniocaudal (A) and mediolateral (B) oblique views.
muscle, a nor mal variant. It is typicall y seen medially on cranio-

Is this a normal mammogram, or do you think
caudal views that include a maximum amount of posterior tissue
(i.e., pectoral muscle is usuall y seen) and can ha ve a v ariety of
What BI-RADS® category would you use? appearances. It is usuall y surrounded by fat and can be round in
shape, as shown here, or it can be more triangular in shape. As in
This is a normal mammogram. Skin folds are noted laterally on the this patient, thin s wirls of fatty tissue are seen in the “mass. ” The
craniocaudal (CC) views. These often develop as the technolo gist oblique view is nor mal, as are an y lateral vie ws that ma y be
actively tugs on the lateral aspect of the breasts in an attempt to obtained. Although it has been repor ted in as man y as 8% of the
include as much lateral tissue as possib le. Pectoral muscle can be population, based on cada veric studies, the ster nalis muscle is an
seen posteriorly on the CC vie ws. On the mediolateral ob lique uncommon finding on mamm graphic studies. It is more com-
(MLO) views, the pectoral muscles are thick in the axillary region, monly unilateral, but can occur bilaterall y and typicall y runs
extend to the level of the nipples, and have a convex anterior mar- parasternally, from the infracla vicular area to the caudal aspect,
gin indicating excellent positioning technique. lying anterior to the medial margin of the pectoralis major muscle.
Oh. . . you ask. . . what about the mass partially visualized at the No additional e valuation is indicated. BI-RADS® cate gory 1:
posteromedial edge of the left breast on the CC vie w (Fig. 1.31C, negative. Next screening mammogram is recommended in 1 year.
arrow)? Where is this on the MLO vie w? This is the ster nalis
Figure 1.31. (Continued) Craniocaudal views (C) photographically coned. Sternalis muscle (arrow).
PATIENT 32
Figure 1.32. Right craniocaudal view, photographically coned laterally.
made but before processing. If the film is palpated at this site,

What is the observation? When did this occur, before
crimp will be found corresponding to the artifact.
or after the exposure was made?
A curvilinear, plus-density artifact from a nail is present, reflectin

improper handling or pressure on the film, after the xposure was
PATIENT 33
Figure 1.33. Craniocaudal (A) view,

B photographically coned. Mediolateral
oblique (B) view, photographically coned.
What is the observation? When did this occur, before

or after the exposure was made?
Curvilinear, negative-density artifacts, from finge prints, reflec

improper handling or pressure on the films before the xposure was
made. Films should always be handled by the edges.
PATIENT 34
B Figure 1.34. Craniocaudal (A) view, photographically

coned. Craniocaudal (B) view, photographically coned.
What observations can you make? What happened? What is the recommendation with respect to the amount
of time that should elapse between loading cassettes
On these images, a high-density artifact is present, surrounded by an with film and making an exposure, and why is this
area of blurring. This is consistent with poor film–screen contact.The recommended? How often should screens be cleaned?
artifact is on the screen and prevents the film from making direct con
tact with the screen. The blur surrounding the artifact reflects the lac It is recommended that appro ximately 15 minutes be allo wed to
of direct contact between film and screen. Depending on the size an elapse between loading a cassette with film and making a
shape of the ar tifact, the high-density material v aries in size and exposure. This is so any entrapped air between film and screen ca
shape and with it the sur rounding area of b lur. Unlike motion blur, escape and good film–screen contact can d velop. Screens should
this type of nonnsharpness is more localized, symmetric, and the area be cleaned at least w eekly or immediately after dust ar tifacts are
of blur is more geometrically marginated. noted in an image by either the technologist or radiologist.
PATIENT 35
B
Figure 1.35. Screening study, 42-year-old woman. Craniocaudal (A) and mediolateral ob lique
(B) views.
What is your observation?
These are nipple rings: They are used uni- or bilaterall y and are
variable in shape.
PATIENT 36
Figure 1.36. Craniocaudal view, right breast, photographically coned.
What is the observation?
Static results in fogging of the film in a airly distinctive appearance

and is related to the processor (as in this patient) or improper fil
handling.
PATIENT 37
Figure 1.37. A: Mediolateral oblique views, pho-

B tographically coned. B: Mediolateral oblique views,
(e.g., skirt and blouse or pants and b louse) to facilitate changing

What is the observation?
for the e xam. If at the time of the mammo gram the patient
states that she is wearing deodorant, an attempt is made to have her
High-density material observed bilaterally in the axilla simulating
wipe it clean before an y images are tak en. We provide spray
calcifications reflects the presence of deodorant. A prominent skin
deodorant in the dressing rooms for patients to use following their
fold and an axillar y lymph node are present, superimposed on the
mammogram.
right mediolateral oblique view (Fig. 1.37B).
When a mammogram is scheduled, what instructions

may be helpful for the patient in preparation for her
mammogram?
Patients are asked to not appl y deodorant prior to their mammo-

gram. They are also advised to consider wearing a two-piece outfi
PATIENT 38
Figure 1.38. Screening study, 49-year-old woman. Craniocaudal (A, B) view. Screening study, 49-year-old woman.
Mediolateral oblique (B) view.
miasis, cutaneous myasis, etc). The dead parasites calcify, resulting

How would you describe the findings, and what is the
in distinctive linear, curvilinear, coiled, lacelike, beadlike, or ser-
diagnosis?
piginous calcifications scattered bilateral y. Sharply define , round
What BI-RADS® category would you use? and punctate calcifications, limited to the pectoral muscles bilater
ally, are seen in women with trichinosis.
Multiple clusters of coiled, serpiginous, linear and curvilinear cal- BI-RADS® category 1: negative. Next screening mammogram
cifications are present bilaterally. These findings are consistent wit is recommended in 1 y ear. BI-RADS® category 2: benign findin
calcified parasites. Several different parasites have been reported as is used if the calcifications are described in the body of the repo t.
occurring in the breast parenchyma or subcutaneous tissue (filaria Next screening mammogram is recommended in 1 year.
sis, loiasis, onchocerciasis, cysticercosis, dracunculosis, schistoso-
Figure 1.38. (Continued) Mediolateral oblique (C) view, right breast, photographically coned. Calcified parasites
PATIENT 39

is recommended in 1 y ear. BI-RADS® category 2: benign findin
is used if the lipoma is described in the body of the repor t. Next
Multiple axillary and intramammary lymph nodes are noted bilaterally,
screening mammogram is recommended in 1 year.
as are benign-type skin and vascular calcifications. A radiolucent mass
Lipomas are slo w-growing tumors presenting as soft, discrete,
is imaged in the right pectoral muscle consistent with a lipoma (F ig.
round, single or multiple masses, most commonly in the subcutaneous
1.39C). The differential for radiolucent masses in the breast is limited
tissues; however, they can develop anywhere, including in breast tis-
and includes lipomas, oil c ysts, and, rarely, galactoceles. Although
sue, muscles, and internal organs. Rarely, they can be associated with
ultrasound is not needed because the diagnosis is established mammo-
hereditary multiple lipomatosis, adiposis dolorosa (Dercum disease),
graphically, ultrasound is sometimes helpful in distinguishing between
and Gardner syndrome. They are composed of mature adipocytes that
a lipoma and an oil c yst. Lipomas are often homo geneously iso- to
may be surrounded by a fibrous capsule.Although most do not require
slightly hyperechoic, well-circumscribed solid masses. Oil cysts have a
treatment, steroid injections, liposuction, or sur gery are options that
variable appearance on ultrasound , ranging from c ystic to comple x
have been described for their management.
cystic to solid masses, some with associated shadowing.
Figure 1.39. Chest CT scan (C) confi ms the presence of a lipoma in the right pectoral muscle (CT scan w as done for reasons
other than the lipoma).
PATIENT 40
Figure 1.40. Screening study, 63-year-old woman. Craniocaudal (A) and mediolateral oblique
(B) views.
margins of the scar not b y invading surrounding tissue. They arise

What is your diagnosis? Does this patient require any
in the first 4 eeks following injury and are characterized by rapid
additional evaluation?
growth followed by regression. The collagen fibers in ypertrophic
scars are oriented parallel to the skin surf ace. In contrast, k eloids
Multiple densities of v arious sizes and shapes, some appearing
extend beyond the borders of the original w ound and involve the
tubular, are seen bilaterally. Associated round, lucent-centered cal-
adjacent normal dermis. These lesions typically appear later, grad-
cifications consistent with skin calcifications are also present. The
ually progress, and can proliferate indefinite y; they do not regress.
margins of some of these densities are par tially or completely out-
The collagen fibers in eloids are larger, thicker, wavier, and ran-
lined by a shar p lucency consistent with air (F ig. 1.40C). The
domly distributed as compared to those found in h ypertrophic
sharply defined ma gins in conjunction with the shapes of these
scars. Hypertrophic scars and k eloids are often f amilial and are
structures and the associated skin calcifications suggest that thes
associated with a higher incidence of occur rence in b lack and
may represent keloids forming at prior sites of sur gery. Review of
Hispanic patients.
prior mammograms with markers placed at the prior biopsy sites
Various theories have been advanced into the causes of k eloid
confi ms this impression (Fig. 1.40D–G). No fur ther evaluation is
formation. These include increases in g rowth-factor activity (e.g.,
indicated.
transforming growth factor and platelet-deri ved growth factor),
alterations in the extracellular matrix, abnormal regulation of colla-
gen turnover, mechanical tension on the healing w ound, genetic
is used if the k eloids are described in the body of the repor t. Next
factors leading to abnor mal immune responses to der mal injury,
screening mammogram is recommended in 1 year.
and an immune reaction to sebum. Various treatments including
Wound healing is a complex process controlled by soluble medi-
steroid (triamcinolone) injections, surgery, radiation therapy, topi-
ators characterized b y a fine equilibrium bet een the deposition
cal application of silicone gel, pressure therapy, laser, intralesional
and removal of structural proteins and glycoproteins. Disruption in
5-fluorouracil, interferon, retinoids, calcium channel b lockers,
these normal anabolic and catabolic processes can lead to abnormal
cryosurgery, and antihistamines have been tried. Results, however,
wound repair and scar formation, including hypertrophic scars and
have been mixed, and the treatment and management of patients
keloids. Hypertrophic scars are raised but typically confined to th
with keloids remains a challenge.
borders of the original wound and increase in size by expanding the
Figure 1.40. (Continued) Mediolateral oblique (C) view, right breast, photographically coned. Sharp lucency con-
sistent with air partially outlines the lobulated mass. Adjacent lucent-centered calcifications consistent with skin calci
fications are noted. Craniocaudal (D) and mediolateral oblique (E) views taken 1 year prior to (A) and (B) with metal-
lic wires used to mark prior biopsy sites and keloids.
Figure 1.40. (Continued) Mediolateral oblique (F) view, left breast, and craniocaudal (G) view, right breast, photo-
graphically coned. Metallic wires used to mark prior biopsy sites and k eloids. The linear and cur vilinear shape and
sharply defined ma gins resulting from air surrounding the protuberant portion of the keloids are diagnostic. Associated
lucent-centered calcifications consistent with skin calcifications are also note
PATIENT 41
A B

is used if the metallic fragments are described in the body of the
Buck shot and bullet fragments with associated shrapnel are pres-
ent in the left breast. Although the buck shot is distributed ran-
domly, the bullet fragments and shrapnel demonstrate a more linear
distribution, delineating the path of the bullets in the breast. No fur-
ther intervention is warranted.
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Cha p t e r 2
Screening
F F
■ TERMS
Apocrine carcinomas Exaggerated craniocaudal views Milliamperage output (mAs)
Artifacts laterally (XCCL) Mondor disease
Axillary nodal metastasis Exposure Ninety-degree lateromedial views (LM)
Batch interpretation Fibroadenoma Ninety-degree mediolateral views (ML)
Biopsy changes Focal parenchymal asymmetry Poland syndrome
Breast cancer statistics Global parenchymal asymmetry Posterior nipple line (PNL)
Call-back (recall) rates Invasive ductal carcinoma, not Reduction mammoplasty
Contrast otherwise specified (NOS) Quantum mottle
Craniocaudal views (CC) Invasive lobular carcinoma Shrinking breast
Cysts Isolated tumor cells Screening guidelines
Diffuse changes Kilovoltage peak (kVp) Screening views
Distortion Lymphovascular space involvement Sharpness
Ductal carcinoma in situ (DCIS) Mediolateral oblique views (MLO) Triangulation
Micrometastasis
■ INTRODUCTION breast cancer screening guidelines that were adopted and published by
the American Cancer Society (ACS) in 2003. The ACS recommends
Mammography can demonstrate clinicall y occult breast cancers. Is annual screening mammography starting at age 40 years and continu-
this significant? Does this ma e a difference? Does finding clinical y ing for as long as a w oman is in good health. Clinical breast e xams
occult cancers affect overall mortality from breast cancer? Yes, yes, should be part of a periodic health exam about every 3 years for women
and yes. Support for the routine use of screening mammo graphy is in their 20s and 30s and annually for women aged 40 years and older.
provided by results from seven of eight randomized controlled trials Women should report any breast change they detect promptly to their
in large populations of women, including 40- to 49-year-old women. health care provider. Beginning in their 20s, w omen should be told
These studies demonstrated a 20% to 32% reduction in breast cancer about the benefits and limitations of breast self- xamination (BSE). It
mortality among the women invited to undergo screening mammogra- is acceptable for women to choose not to do BSE or to do it only occa-
phy. Updates from the two-county Swedish trial have reported 20-year sionally. Women known to be at increased risk (e.g., personal or strong
survivals of 87.3% and 83.8% among women identified with tumor family history of breast cancer, a genetic tendency or prior mediastinal
0.9 cm and 1.0 to 1.4 cm in size, respecti vely. The goal of screen- radiation therapy for Hodgkin lymphoma) may benefit from earlier ini
ing mammography (and our job), therefore, is to consistently identify tiation of early-detection testing, screening at shorter intervals, and/or
breast cancers that are 1.4 cm (ideally, 0.9 cm). It is noteworthy the addition of breast ultrasound or magnetic resonance imaging
that the most common method of breast cancer detection is no w (MRI). Indeed, since 2003, several reports have supported the use of
screening mammography (as opposed to breast self-e xamination), MRI for the detection of small cancers in high-risk women.
and that mortality rates from breast cancer continue to drop. It was estimated that 211,240 ne w cases of breast cancer w ould
Based on the scientific vidence and expert opinion available, an occur in 2005 among w omen in the United States. Among men,
independent panel of 42 medical and scientific xperts developed new 1,690 new breast cancer cases were expected in 2005. The estimated
72
numbers of deaths resulting from breast cancer in 2005 among In evaluating screening mammograms, I recommend developing
women and men were 40,410 and 460, respectively. A decline in the a viewing strategy that is systematic and is used consistently. I also
mortality rate from breast cancer of 2.3% per y ear from 1990 to think it is important to have a proactive and focused mindset when
2000 has been reported among all women, with larger decreases in reviewing studies, rather than w aiting passively for more subtle
women under age 50 years. The decline in the mortality rate is attrib- findings to become apparent. In other w ords, send your eyes out
uted to earlier detection and improved treatment. looking for potential lesions in specific locations; otherwise ou
may miss subtle findings or study limitations (e.g., lurring) that
may preclude detection of possible abnormalities. Chance favors a
■ SCREENING VIEWS prepared mind. Ideal viewing conditions are equally important. All
extraneous light should be eliminated so that the onl y light in the
Craniocaudal (CC) and mediolateral oblique (MLO) views are the
room is coming through the films being r viewed. Paper work and
standard screening views. In addition to routine views, our technol-
interruptions should be minimized.
ogists obtain anterior compression and e xaggerated craniocaudal
Whatever approach you use, it should begin with a review of the
(XCCL) views, as needed, to tailor the screening study to the indi-
films for technical adequac y. Specifical y, is positioning accept-
vidual woman.
able? Has any tissue, and possibly a lesion, been excluded from the
films (e.g., do y ou see tissue at the edge of an y of the films)? I
■ INTERPRETATION glandular tissue adequately compressed and penetrated (exposed)?
Are the films high in contrast?Are there any artifacts that may pre-
Compared to online reading, batch inter pretation of screening clude adequate interpretation? Is there any blurring?
mammograms is cost-effective and efficient. With batch interpreta- Look for diffuse changes that may be difficult to perceive, par-
tion, the patient leaves the imaging facility after her routine views ticularly if you are focused on detecting smaller potential lesions. Is
are done and reviewed by the technologist for technical adequacy. one breast larger or more dense than the other? Don’ t assume that
The mammograms are hung on high-luminance, dedicated mam- the larger breast is the abnor mal breast; the smaller breast ma y be
mography multiviewers for inter pretation by the radiolo gist at a progressively “shrinking.” Are the technical factors needed for ade-
later time. At our facility, right and left CC and right and left MLO quate exposure of one breast significant y different from those used
views are hung back to back. The two CC views are placed side by to expose the contralateral side? Is compression limited (e.g., cen-
side with the tw o MLO views. If they are available, films from timeters of compression or decane wtons used)? Is there promi-
years before are hung abo ve the cur rent study for comparison. nence of the trabecular markings? Do you see trabecular markings
Subtle changes may not be apparent from one year to the next, but superimposed on the pectoral muscles (e.g., reminiscent of “k er-
may be more easily perceived if a study other than the one from 1 ley” B lines)? Are there any findings in the axilla y regions?
year ago is used for comparison. However, before calling a patient After evaluating the mammo gram globally for technical ade-
back for a diagnostic study , reviewing the mammogram from the quacy and diffuse changes, look specifical y both with and without
year before is often helpful to make sure the current area of concern a magnification lens for masses, areas of asymmet y, architectural
was not evaluated last year. Any additional studies done at our cen- distortion, and calcifications. Na rowing the search is helpful in
ter are kept in jackets close to the multi viewer so that they can be focusing your review. On CC views, look at the lateral, middle, and
reviewed as deemed necessary by the interpreting radiologist. medial thirds of the breasts (Fig. 2.1). On MLO views, evaluate the
RT CC LT CC
Figure 2.1. Image evaluation. On craniocaudal views, nar-

row the search for potential lesions by splitting the images in
thirds. This will help y ou to focus attention on smaller
amounts of tissue. Go back and for th between the right and
left craniocaudal vie ws, looking specifical y for asymme-
tries, possible masses, distortion, or calcifications
74 Chapter 2 • Screening
Figure 2.2. Image evaluation. On mediolateral ob lique

views, narrow the search for potential lesions b y splitting the
images in thirds. This will help y ou to focus attention on
smaller amounts of tissue. Go back and for th between the
right and left mediolateral oblique views, looking specifical y
for asymmetries, possible masses, distortion, or calcifications
upper, middle, and lower thirds of the breasts (Fig. 2.2). Search out tainty in making appropriate recommendations and narrows differen-
potentially abnormal areas as y ou go back and for th between the tial considerations to one or two options. Recommendations are more
right and left breasts. Also, evaluate fat–glandular interfaces specif- easily justified foll wing complete and thorough e valuations. With
ically for straight lines or con vex tissue bulges, the fatty stripe of the confidence generated y the additional e valuation, succinct,
tissue between the pectoral muscle and glandular tissue on MLO definit ve, and directive reports can be generated.
views, the superior cone of tissue on MLO vie ws, the subareolar
areas, and the medial portions of the breasts on CC views (Fig. 2.3).
After formulating a working hypothesis on a given mammogram, ■ MANAGEMENT OF PATIENTS NEEDING
compare it with prior studies and look at the history form for poten- ADDITIONAL EVALUATION
tially relevant factors (hormone replacement therapy, prior breast
surgery, family history of breast cancer, skin lesions etc.). Be care- For women with an ob vious lesion on the screening study , addi-
ful not to let prior films influence decisions garding the relevance tional evaluation helps characterize the e xtent of the lesion and
of a finding on the cu rent study. In some women, it is important to sometimes establishes the presence of other , initially unsuspected,
look at several comparison studies. If you perceive an area of spic- lesions. It provides an opportunity to communicate directly with the
ulation or distortion that cannot be e xplained by a history of sur- patient and undertake imaging-guided biopsies at the time of call-
gery, trauma, or mastitis at that specific site, the patient should b back. In essence, we expedite patient care. Consequently, the only
evaluated in spite of apparent stability. Stability of a lesion does not BI-RADS® assessment cate gories I use on screening studies are
assure that it is benign. category 1 (negative), category 2 (benign finding), and cat gory 0
Make no assumptions. If you assume something is benign or (needs additional imaging evaluation or needs prior mammograms
malignant, it becomes v ery difficult to think otherwise. Also, if for comparison).
there is an obvious finding, ma e a conscientious effort to look at Category 0 is used when additional studies are indicated or when
the remainder of the mammogram first. Do not focus our attention prior studies are to be requested and comparison is needed to mak e
on obvious finding to the exclusion of other subtle, and potentially a final assessment. or those women in whom a potential abnormal-
more significant, finding ity is detected, we categorize the call-back as level 1, 2, or 3. These
On screening studies, my goal is to detect potential abnormalities. levels are used internally to indicate the amount of time that should
I make no particular effort to characterize potential or true lesions on be allotted for the patient’s diagnostic appointment. F ifteen, thirty,
screening studies. Over the years it has become apparent to me that and sixty minutes are allowed for level 1, 2, and 3 call-backs, respec-
sometimes what I think is a significant lesion on the screening mam tively. In general, level 1 designates those patients for whom physi-
mogram turns out to be insignificant after additional valuation and cal examination, additional mammo graphic images, or an ultra-
what I initially think is almost certainly benign is cancer. Similarly, in sound are all that should be needed to resolv e the question. If the
some patients, what is seen on the screening studies turns out to rep- interpreting radiologist expects that a patient will need additional
resent a more extensive lesion (“the tip of the iceber g”). Why make mammographic images and an ultrasound , the call-back is desig-
decisions with insufficient and potentially misleading infor mation? nated as level 2. When the radiologist expects that the patient will
Why work with low confidence? Additional evaluation increases cer- need a biopsy, level 3 is used so that an adequate amount of time is
Figure 2.3. Image evaluation. A: On the craniocaudal

views, evaluate areas w here breast cancers are lik ely to
develop—specifical y, the medial quadrants, subareolar areas,
fat–glandular interfaces, and the retroglandular areas posteri-
orly. B: On the mediolateral ob lique views, evaluate areas
where breast cancers are lik ely to develop—specifical y, the
fatty stripe of tissue between the pectoral muscle and glandu-
lar tissue, the superior cone of tissue, subareolar areas, and the
inferior aspects of the breasts.
available to do a biopsy when the patient returns for additional eval- process for reviewing her mammogram, issuing a report to her doc-
uation. Although this is an arbitrar y classification, characterized y tor, sending her a letter with results, and the possibility of being
times when, after completing the e valuation, a le vel 1 call-back called back for a diagnostic evaluation. It is important for women to
patient requires a biopsy and a level 3 call-back patient does not, the be informed of the process and to know that being called back does
system works well. It provides for more efficient use of the schedule not necessarily mean they have cancer. Our goal is to minimize
and allows us to complete evaluations in one visit. It has enabled us some of the anxiety e xperienced by patients when they are called
to optimize patient care in a practical and cost-effective manner. back for additional evaluation. It does not always work, but it does
At the time of the screening study , the technologist informs the help some women.
patient about the possibility of a call-back for further evaluation. In All women who require additional e valuation are contacted
addition, each woman is given a written statement that describes the directly by a member of our staf f. By communicating with the
patient directly, we can explain the reason for the call-back more at times is (unfor tunately) grossly underestimated. Re gardless of
appropriately than others might (e.g., as opposed to having a refer- how much you try to prepare a woman for the possibility of a call-
ring physician’s office tell the patient that the first images ta en back, it is guaranteed to provoke anxiety and stress in most women.
were no good), and w e reassure the patient re garding the need for High recall rates are also associated with increased costs and
additional studies. This method also e xpedites patient care b y decreased efficien y of screening programs. Counter this with our
decreasing the amount of time needed to schedule the diagnostic goal of never missing an oppor tunity to diagnose an earl y breast
evaluation. If we are unable to contact the woman by phone within cancer. Undoubtedly, to call back or not is a fine line that needs to b
48 hours following her screening study, we send a letter via regular considered carefully. Depending on the a vailability of prior films
mail asking her to call us. If after a week from mailing the letter we you can expect call-back rates to be higher among w omen with no
still have not heard from the patient, a cer tified letter is mailed to prior studies compared to those w omen in w hom prior films ar
her with a copy to the referring physician. All efforts to communi- available. In considering the call-back rate for indi vidual radiolo-
cate with the patient are documented in her chart. gists, I think it is impor tant not to consider this a static figure bu
A report is generated for all studies in which a prior mammogram rather a work in progress. Early in the career of a radiolo gist one
is requested and comparison is needed to mak e a final assessment should expect and accept higher call-back rates. Ho wever, the rate
These reports are assigned to a category “0”; we do not keep undic- should decrease progressively with the number of screening mam-
tated studies aside pending arrival of comparison films. By generat mograms evaluated over time. Although it is incon venient and not
ing a report, the referring physician is informed that we are working usually easy to schedule, the ideal lear ning situation is for the radi-
on obtaining prior studies and a system to track the patient is set in ologist recommending the call-back to be the one in volved in the
motion that minimizes the lik elihood of a patient “f alling through diagnostic workup. Under these circumstances, meaningful call-
the cracks.” We allow a 2-week interval during which we make every back rates can be generated and improvement shown over the years.
effort to locate prior studies; this includes calling the f acility indi- It is also important to recognize that most call-backs for diagnostic
cated by the patient on her history form. If this action is unsuccess- evaluations do not lead to biopsies. Based on published reports, the
ful, we contact the refer ring physician and request prior mammo- American College of Radiolo gy recommends that call-backs be
gram reports that will indicate the name of the f acility and the date maintained at a rate of 10% or less.
of the prior study. Lastly, we sometimes call the patient to verify the
information she provided. If we are unable to obtain prior films afte
2 weeks, an addendum to the initial repor t is issued and we dictate ■ CONCLUSION
the findings as though there ere no prior studies. Ev ery effort we
make to procure prior studies is documented in the patient’s file In this chapter, the screening mammogram is the starting point for
all patients discussed. F ocus your attention initially on systemati-
cally reviewing the images as described abo ve. Determine if the
■ CALL-BACK RATES mammogram is normal or potentially abnormal. Some differentials
are included, and pathology results are provided for those patients
What is an appropriate call-back (recall) rate? This is an impor tant for whom biopsy is appropriate. I also need to state the ob vious at
question to consider and is something radiologists involved in screen- the onset of this chapter: What I present is an artificial situation. For
ing mammography should monitor routinel y. Calling a patient back didactic purposes, I have presented a significant number of patient
for diagnostic evaluation is not innocuous and should never be trivial- with breast cancer in this chapter; in a true screening program, most
ized. In some women, it is associated with signif cant morbidity that of the mammograms you review are normal.
PATIENT 1
Figure 2.4. Screening studies. Mediolateral oblique (A) and craniocaudal (B) views.
breast needs to be lifted (e.g., not sagging or drooping) so that the

In assessing images for technical adequacy, what
inframammary fold is open and a small amount of upper abdomen is
factors should you evaluate? included on the image (Fig. 2.4A). As the technologist positions the
breast, she needs to estab lish the angle of ob liquity of the patient’s
The technical f actors you should e valuate before focusing on
pectoral muscle; it is easier to mobilize tissue maximally away from
potential abnormalities include positioning, compression, e xpo-
the body if it is pulled parallel to underlying muscle fibers. Using th
sure, contrast, sharpness, noise, artifacts, and film labeling. As an
appropriate angle for the patient and having the patient lean in slightly
interpreting radiologist, you are the gatekeeper for image quality
to relax the muscle, the technologist needs to mobilize the breast and
and overall patient care at your facility. If you are willing to rou-
muscle medially as much as possible and maintain the medial mobi-
tinely interpret suboptimal studies without a good explanation that
lization of the breast as compression is applied and the breast is
is well documented (a patient with P arkinson’s disease, a frozen
lifted up and pulled out. If an incorrect angle of obliquity is selected,
shoulder, history of stroke, etc.), you are basically willing to accept
the breast is not mobilized as much as possib le medially, or if the
a potential delay in the diagnosis of breast cancer. The overall qual-
patient moves out of the unit as compression is applied, the pectoral
ity bar at your facility will be as high as you set it.
muscle may not be thick at the axilla, extend to the level of the nip-
In evaluating positioning on mediolateral ob lique (MLO) views,
ple, or it may have a concave margin, a triangular shape, or be paral-
the pectoral muscles should be wide in the axillar y regions, extend
lel to the edge of the film ( ig. 2.4C).
to the level of the nipples, and have convex margins anteriorly. The
Figure 2.4. (Continued) 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 nip-
ple. The shape of the muscles is triangular . Repeat mediolateral ob lique (D) views, using optimal technique,
show thick pectoral muscles at the axilla with convex anterior margins extending to the level of the nipples.
on the CC view, look for cleavage as an indication that medial tis-

Positioning
sue has not been excluded from the image. If no pectoral muscle or
cleavage is seen, measure the posterior nipple line (PNL) on the
In positioning patients for craniocaudal vie ws, the technolo gist
MLO view and compare it with the measurement on the CC vie w
needs to identify the inframammary fold and lift the breast as much
(Fig. 2.4E, F). The measurements should be within 1 cm of each
as the natural mobility of the breast permits. Next she needs to pull
other. Also, evaluate the lateral aspect of the images. If there is tis-
the breast tissue out and acti vely tug on the lateral aspect of the
sue extending to the edge of the film, the technol gist did not pull
breast so as to include as much posterolateral tissue as possible. On
lateral tissue in, or an e xaggerated craniocaudal vie w laterally
craniocaudal (CC) views, you should expect to see pectoral muscle
(XCCL) may need to be done to evaluate the patient adequately in
in 30% to 40% of patients. When you see pectoral muscles on the
the craniocaudal projection.
CC views, you can be assured that posterior tissue has been
included on the images (F ig. 2.4B). If pectoral muscle is not seen
1.
NL)
le line (P
r nipp
sterio
2. po
posterior nipple line (PNL)
Figure 2.4. Posterior nipple line. E: The posterior nipple

line (PNL) is measured w hen it is suspected that posterior
tissue is e xcluded on a craniocaudal (CC) vie w. It is most
useful when positioning on the cor responding 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 measure-
ment provides an estimate of the amount of tissue that should
be included on the CC vie ws. F: On the CC view, the PNL
extends from the nipple to the edge of the film.The measure-
F ment of the PNL on the CC vie w should be within 1 cm of
that measured on the MLO view.
Figure 2.4. (Continued) Craniocaudal (G) and mediolateral oblique (H) views.
right CC view. A significant amount of posterior tissue is xcluded

What are your observations concerning the positioning
from the right CC vie w and therefore it needs to be repeated.
on this patient’s mammogram? Focusing on technique, a repeat CC vie w (Fig. 2.4K) is obtained
and demonstrates a significant y greater amount of tissue. There is
Retroglandular fat is seen laterall y on the left craniocaudal vie w.
now fat at the edge of the film and the PNL measurement on thi
Tissue is seen extending to the edge of the film on the right cranio
second CC view (Fig. 2.4L) is 10 cm, w hich is equal to w hat is
caudal view, and although the right breast is smaller than the left, is
measured on the MLO vie w. If images that are missing 2.8 cm of
there an adequate amount of posterior tissue on the right craniocau-
posterior tissue (as on the original right CC view in this patient) are
dal view? How can you determine this? Measuring the PNL is help-
accepted and inter preted, our goal of finding cancers that are les
ful in assessing if the amount of tissue imaged on the craniocaudal
than 1 cm in size is compromised significant y.
view is adequate (F ig. 2.4I, J). In this patient, the PNL measure-
ment on the right MLO view is 10 cm, compared to 7.2 cm on the
Figure 2.4. (Continued ) Mediolateral oblique (I) and

craniocaudal (J) views showing the posterior nipple line
J measurements. An inadequate amount of tissue is included
on the right craniocaudal view.
Figure 2.4. (Continued) Repeat right craniocaudal (K)

view. Fat is now seen at the edge of the film. Repeat righ
craniocaudal (L) view with the posterior nipple line meas-
L uring 10 cm, which is comparable to that measured on the
original mediolateral oblique view.
In addition to positioning, compression needs to be assessed b y retroglandular fat is dark g ray or nearl y black in high-contrast
specifical y evaluating the images for une ven or inadequate e xpo- images. Poor-contrast images are characterized b y dull gray retro-
sure, motion blur, and poor separation of parenchymal densities. glandular and subcutaneous fat, and the skin is readily apparent.
Sharpness needs to be evaluated by looking specifical y for blur-
ring (i.e., unsharpness). The most common cause of blur is patient
Additional Technical Factors to Assess motion. This is why adequate breast compression is critical. Shor t
exposures (ideally, 2 s) are also helpful in minimizing motion
Glandular tissue needs to be adequatel y exposed so that there is blur. Motion blur does not always involve the entire image. It can be
visualization of trabecula, small tubular str uctures, and vessels. In localized to one area on the mammo gram, where it is commonl y
many women, adequate penetration of the glandular tissue overex- caused by lack of unifor mity in breast compression. P oor fil
poses the skin and subcutaneous tissue. Image contrast is also screen contact can also be a cause of localized unshar pness.
important. Ideally, contrast is maximized so that subtle density dif- Sharpness is also af fected by focal spot size, object-to-image dis-
ferences in glandular tissue can be appreciated. Subcutaneous and tance, and source-to-image distance. Increases in focal spot size
and object-to-image distance as w ell as decreases in source-to- pick-off, moisture, incorrect film loading so that the emulsion sid
image distance contribute to geometric unsharpness. is away from the screen, fo g, static, foreign objects on the screen,
The ability to detect small str uctures such as calcifications i etc.). Ideally, most images are artifact free. Depending on the over-
decreased by noise (e.g., radiographic mottle). Quantum mottle is all effect on image quality , films with a tifacts may need to be
the major cause of noise in mammography. Noise can be identifie repeated.
on an image b y a backg round density that is not homo geneous With respect to film labeling, the foll wing information is
and results in loss of shar pness and visualization of lo w-contrast required on all films: patient name, unique patient identificati
structures. number, date of study, radiopaque laterality and projection markers
Artifacts can result from x-ra y equipment (filte , compression placed closest to the axilla, f acility name, f acility location (city,
paddle, image receptor holder, grid, etc.), patient f actors (deodor- state, and Zip code), technolo gist identification, cassette/scree
ant, hair, jewelry, tattoos, etc.), and cassette, film, and screen actors identification number, and mammography unit identification num
(upside-down cassette in bucky, film scratches, dents, fing prints, ber if there is more than one unit in the facility.
PATIENT 2
are abnormal, asymmetric changes may be the result of chest w all

How would you describe the findings on this
trauma (e.g., bur ns), congenital abnor malities (e.g., P oland syn-
mammogram? drome), or sur gery. Invasive ductal carcinomas can present with
global areas of parenchymal asymmetry, but these are usually clin-
Compared to the left breast, the right breast is smaller , with
ically apparent and readil y palpable. Invasive lobular carcinoma
dense, asymmetrically distributed tissue (i.e., global parench y-
can also present with global areas of parench ymal asymmetry and
mal asymmetry). Although breast size and tissue are commonl y
progressive changes in breast size (either increases or decreases);
symmetric, asymmetries in breast size and tissue distribution can
palpable findings m y be present, but they are often more subtle in
be seen in numerous women as a normal variant. No mass or dis-
patients with invasive lobular carcinomas. Rarel y, lymphoma can
tortion is noted in the area of increased tissue on the right. The
present with diffuse, asymmetric involvement of one breast.
tissue in the right breast is scalloped and contains areas of f atty
lobulation. A solitary dense dystrophic calcification is present i
the right breast. What do you think about the amount of posterior tissue
imaged on the right craniocaudal view?
What two pieces of information are critical in this What BI-RADS® category would you assign?
patient? Are you sure?
In this woman, it is important to determine that there is no palpable Pectoral muscle and retroglandular fat are imaged on the right cran-
abnormality in the right breast and that the asymmetr y in size iocaudal view and there is no tissue e xtending to the edge of the
(either a decrease in size on the right or an increase in size on the film, so it is unlik ely that posterior tissue has been e xcluded from
left) is not a new or developing change. If they are available, com- the image.
parison with multiple prior studies is critical, as is a history of prior No change is noted in comparing with multiple prior studies (not
right breast surgery or trauma. If there is any question about a cor- shown).
responding palpable abnormality or a progressive change in breast This is cate gorized as BI-RADS® cate gory 1: ne gative. BI-
size, the patient can be ask ed to retur n for cor relative physical RADS® category 2: benign finding can be used if the obse vations
examination and, if needed, additional mammographic views, ultra- are described in the repor t. Annual screening mammo graphy is
sound, or, occasionally, magnetic resonance imaging. When they recommended.
PATIENT 3
(B) views.
Based on the location of this area on the CC view, look specifical y

What do you think of the positioning on the
at where you would expect to find the co responding area on the
craniocaudal (CC) views? MLO view. Using the distance of this area from the nipple on the
What BI-RADS® category would you assign, and what CC view (Fig. 2.6C), generate an arc on the MLO view (Fig. 2.6D)
is your recommendation? to help you approximate the expected location of this area on the
MLO view.
Patient positioning in this study is acceptable. Although no pectoral With the exception of some in vasive lobular carcinomas, most
muscle is seen on the craniocaudal views, cleavage is seen medially breast cancers are three-dimensional str uctures with comparab ly
and there is retro glandular fat bilaterally (i.e., no tissue is seen at sized and shaped abnor malities on any view of the breast. In this
the edge of the films). A lymph node is noted superimposed on the woman, there is no comparable area in size, shape, or density on the
left pectoral muscle, and one is seen laterall y on the right cranio- MLO view. For potential lesions 1 cm in size noted on one view,
caudal view. a comparable abnormality should be identified on the other projec
tion at approximately the same distance from the nipple.
BI-RADS® category1: negative. Annual screening mammogra-
What do you think of the rounded area of asymmetric
phy is recommended.
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?
Figure 2.6. (Continued) Craniocaudal (C) and medio-

lateral oblique (D) views. The distance to the possib le
lesion is measured from the nipple as “X” cm on the
craniocaudal (CC) vie w. As “X” cm is measured back
from the nipple on the mediolateral oblique (MLO) view,
an arc can be created that describes the approximate loca-
tion for the possible lesion noted in the right CC view. No
comparably sized area is identified in the MLO vi w.
D Intramammary lymph nodes described above are within
the circles on the images.
PATIENT 4
B
asymmetric tissue is often planar (i.e., best seen in one projection and
What do you think?
changes significant y in appearance on other vie ws), scalloped, het-
What BI-RADS® category would you assign, and what erogeneous in density because of interspersed f at, and characterized
is your recommendation? by a g radual change in density at the mar gins. Masses are three-
dimensional, with an abrupt change in density and a bulging (convex)
A rounded, asymmetric island of tissue is noted laterall y in the left margin. True lesions, par ticularly when 1 cm, are of comparab le
breast. However, in evaluating the mediolateral oblique view, no com- size, shape and density on the tw o standard projections and are at
parably sized or shaped area is identified that ould correspond to the approximately the same distance from the nipple on the two views.
approximate location of this area on the craniocaudal view. Relatively BI-RADS® category 1: negative. Annual screening mammogra-
low-density tissue is seen superiorl y, characterized b y scalloping, phy is recommended.
interposed fat, and a gradual transition in density. As illustrated here,
PATIENT 5
B Figure 2.8. Initial screening study , 41-year-old woman.

Craniocaudal (A) and mediolateral oblique (B) views.
What do you think? What do you think of this predominantly fatty pattern in
What BI-RADS® category would you assign, and what a 41-year-old woman?
is your recommendation?
Although it is routinel y suggested that mammo graphy in y oung
A focal area of parench ymal asymmetry is present in the upper women is not v ery good because dense tissue precludes the detec-
outer quadrant of the left breast. It is of comparable size and density tion of breast cancer , it is clear that age alone cannot be used to
and is at the same approximate distance from the nipple on the two establish the density of the parench ymal pattern in an indi vidual
projections. Differential considerations include nor mal variant, woman. Regardless of childbearing, y oung women can have com-
hormone replacement therapy effect, asymmetry secondary to prior pletely fatty tissue and older , postmenopausal w omen can ha ve
surgical excision of the cor responding tissue in the right breast, dense tissue. It is also important to recognize that there is large intra-
focal fibrosis, pseudoangiomatous stromal yperplasia (PASH), and interobserver variability in the application of arbitrarily define
posttraumatic changes (evolving hematoma, fat necrosis), mastitis, parenchymal patterns. Additionally, the perceived density of a tissue
fibroadenolipoma (hamartoma), invasive ductal carcinoma not oth- pattern is dependent on technical f actors. Some “extremely dense”
erwise specifie , invasive lobular carcinoma, and lymphoma. tissue is inadequately exposed fibr glandular tissue.
If, as in this woman, no prior studies are available for comparison,
spot compression vie ws and possib ly ultrasound with cor relative
physical examination can be under taken to exclude an underlying
malignancy.
BI-RADS® category 0: need additional imaging evaluation.
C D
Figure 2.8. (Continued) Craniocaudal (C) and mediolateral oblique (D) spot compression views.
regardless of projection. They are also characterized b y an abrupt

What do you think now?
change in density at the margins. The patient has no history of breast
What BI-RADS® category would you assign at this surgery and recalls no trauma to the left breast. Physical examination
point, and what is your recommendation? of this area is normal and symmetric with the comparable site on the
contralateral breast. No tender ness is elicited. Ultrasound demon-
Normal tissue is imaged on the spot compression vie ws. The overall strates normal tissue throughout the upper outer quadrant of the left
appearance and density of this tissue is different in the two projections; breast. This is benign focal parenchymal asymmetry, a normal variant.
there is scalloping and f atty tissue is interspersed with the glandular BI-RADS® category 2: benign finding. Annual screening mam-
tissue. There is a gradual change in density at the margins. In contrast, mography is recommended.
masses are three-dimensional with comparab le size and density
PATIENT 6
How do you evaluate a screening mammogram? What is your differential for architectural distortion?
The evaluation of screening mammograms can be approached in dif- Among the benign possibilities, consider f at necrosis related to
ferent ways. Develop a strategy that is systematic and use it consis- trauma or prior surgery, mastitis, complex sclerosing lesions (scle-
tently. Take a proactive approach, and acti vely send your eyes and rosing adenosis), papilloma, and focal fibrosis (rare). I vasive duc-
brain looking for particular abnormalities in specific locations (sub tal carcinoma not otherwise specified (NOS), tu ular carcinoma,
areolar area, medially on craniocaudal vie ws, etc.). This helps you ductal carcinoma in situ (rare), and in vasive lobular carcinoma are
stay focused and minimizes the likelihood that you will miss signifi among the invasive lesions that may present with architectural dis-
cant findings. Whatever approach you settle on, it should include a tortion. Armed with differential considerations, you can sort through
review of the films for technical adequa y. Specifical y, is the posi- them by integrating the imaging features of the lesion in question
tioning acceptable? Has tissue and possib ly a lesion been e xcluded with the patient’s age, pertinent history, and physical examination. If
(e.g., do you see tissue to the edge of an y of the films)? Is glandula you develop and routinely follow a simple, logical, and systematic
tissue adequately compressed and penetrated? Are the films high i approach, the next appropriate step becomes readily apparent and is
contrast? Are there any artifacts that may preclude adequate interpre- justifia le. This approach is rarely misleading.
tation of the films? Is there a y blurring? Before focusing on per-
ceiving localized findings, look for global or di fuse changes. These
may be difficult to appreciate once you focus your attention on more
What, if any, history would keep you from calling this
subtle findings patient back?
After evaluating the mammogram at a distance for technical ade- What BI-RADS® assessment category would you
quacy and diffuse changes, look specifical y (with and without a assign, and what is your recommendation?
magnification lens) for masses, focal areas of asymmetry, architec-
tural distortion, and calcifications. It is helpful to na row your In this patient, the overall characteristics of the lesion include long
search, so on craniocaudal (CC) views, focus on the lateral, middle, spicules, no significant central densit , and a more pronounced
and medial thirds of the breasts (F ig. 2.1). On the mediolateral appearance in one of the two routine views. It is critical to establish
oblique (MLO) views, focus on the upper, middle, and lower thirds if the patient has had a biopsy (or significant trauma) in the righ
of the breasts (F ig. 2.2). Search out potentiall y abnormal areas as subareolar area. If there is a history of prior surgery, the location of
you go back and for th between the right and the left breasts. the surgical procedure has to correspond directly to the area of dis-
Specifical y, evaluate fat/glandular interfaces, the fatty stripe of tis- tortion. Don’t hesitate to examine the patient to establish the pres-
sue between pectoral muscle and glandular tissue on MLO vie ws, ence of a subtle periareolar scar e ven when the patient does not
the superior cone of tissue on the MLO views, subareolar areas, and recall a prior breast biopsy. A complex sclerosing lesion is a good
the usually fatty tissue mediall y on CC vie ws (Fig. 2.3). After possibility in a w oman with this type of lesion and no histor y of
developing a working hypothesis on a given mammogram, compare surgery or apparent scar on ph ysical examination. Complex scle-
with prior studies and look at the histor y form for any pertinent rosing lesions are often seen better in one projection and , given
information (family history of breast cancer or o varian cancer, their size, usually have no corresponding palpable abnormality on
estrogen use, prior trauma or surgery, etc.). physical examination. In considering mastitis, the breast is usuall y
tender; there may be associated erythema and warmth as well as a
history of prior inflammato y changes in the subareolar area.
What do you think? In thinking about the malignant possibilities, an invasive ductal
carcinoma (NOS) of this size and in this location will almost cer-
In this patient, scattered dystrophic calcifications are present bilater tainly have physical findings, including a palpa le abnormality,
ally. Did y ou find a potential abno mality? If y ou did not, look dimpling, and possibly nipple retraction. Tubular carcinomas are
specifical y for architectural distor tion and move to the subareolar usually fairly small and are more commonly identified in ounger
areas. Architectural distortion is present in the right subareolar area, women (in their 40s). Invasive lobular carcinomas are more com-
best seen on the MLO view (Fig. 2.9C); it is not readily apparent on mon in older patients, and physical findings are often subtle
the CC view (Fig. 2.9D). Is it safe to assume that this is cancer? No! This patient has had sur gery in the right subareolar area cor re-
Benign-appearing lesions can tur n out to be cancer , malignant- sponding to the site of distor tion. The findings reflect at necrosis
appearing lesions can reflect benign changes. Ma e no assumptions, related to the prior biopsy. Architectural distortion related to prior
or you will pigeonhole y ourself and limit y our ability to think surgery is often planar and therefore better seen in one projection,
through the possibilities. Most findings in the breast h ve benign and as in this patient. No additional evaluation is indicated.
malignant etiologies in the differential. Our job is to sort through the BI-RADS® category 2: benign finding. Annual screening mam-
possibilities accurately and efficient y. mography is recommended.
C D
Figure 2.9. (Continued) Mediolateral oblique (C) and craniocaudal (D) photographically coned views. Architectural distortion readily apparent on the
mediolateral oblique view, more subtle on the craniocaudal view.
PATIENT 7
B
wrong during positioning. It is lik ely that an incor rect angle of

What do you think?
obliquity was selected, the muscles w ere not relax ed, and the
What BI-RADS® assessment category would you breasts were not adequately mobilized medially (or if they were, the
assign, and what is your recommendation? patient pulled out during positioning).
On the craniocaudal (CC) vie ws, a significant amount of poste
There are arterial calcifications bilateral y. Did you notice a mass in rior tissue is e xcluded from the images. In deter mining if an ade-
the right breast? This is ne w compared with prior studies (not quate amount of tissue has been included on the CC views, look for
shown). Additional evaluation is recommended. BI-RADS® cate- pectoral muscle posteriorly or for clea vage medially. If neither of
gory 0: need additional imaging evaluation. these is seen, measure the posterior nipple line (PNL) on the MLO
views (and remember that in this patient, positioning on the MLO
Do you have any additional observations? Technically, 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
are you happy with this study? Be specific in
that measured on the CC vie ws (Fig. 2.4E, F). The PNL measure-
describing the problem. ment 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
Positioning on this study is not optimal. There is insufficient pec-
length of the calcified a tery laterally on the right CC and the rela-
toral muscle on the mediolateral ob lique (MLO) vie ws. Ideally,
tionship of the lesion to the edge of the film bet een CC and MLO
pectoral muscle should be seen to the le vel of the nipple; it should
views, it is clear that posterior tissue has been e xcluded on the CC
be thick in the axilla and have a convex anterior margin. Given the
views.
triangular shape of the muscle in this patient, se veral things went
Figure 2.10. (Continued) Craniocau-

D dal (C) and mediolateral ob lique (D)
spot compression views, right breast.
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 confi m the presence of a 1-cm ir reg-

ular mass with spiculated margins. A biopsy is indicated based on
the mammographic findings
E Figure 2.10. (Continued) Ultrasound image (E), radial (RAD) projection of

the lesion.
An irregular, hypoechoic mass with angular margins is imaged at A poorly differentiated, invasive ductal carcinoma is repor ted
the 11 o’clock position, 6 cm from the right nipple, cor responding histologically following the ultrasound guided core biopsy . A 1.2-
to the expected location of the lesion seen mammographically. cm, grade III, invasive ductal carcinoma is reported on the lumpec-
BI-RADS® category 4: suspicious abnor mality, biopsy should tomy specimen. No metastatic disease is identified in four xcised
be considered. An ultrasound-guided core biopsy is done at the sentinel lymph nodes; [pT1c, pN0(sn)(i), pMX; Stage I].
time of the diagnostic evaluation.
F Figure 2.10. (Continued) Ultrasound image (F), radial (RAD) projection.

The lesion is contained in the box.
PATIENT 8
Figure 2.11. Screening study, 51-year-old woman. Craniocaudal

(A) and mediolateral oblique (B) views. The metallic BB on the left
B is on a skin lesion. No histor y of breast sur gery or significan
trauma.
fications on e very screening mammo gram you review, you are

Any observations?
unlikely to miss the rele vant finding in this patient. Did ou see the
What BI-RADS® assessment category would you cluster of calcifications anterior y at appro ximately the 6 o’clock
assign, and what is your recommendation? position in the right breast? With what degree of confidence can ou
characterize these, and how definit ve can you be with respect to their
Systematically review the images and acti vely look for potential significance? Why not get more infor mation in the for m of double
lesions. In addition to splitting the craniocaudal (CC) and mediolat- spot compression magnification vi ws? There are other calcification
eral oblique (MLO) views into thirds and e valuating the locations posteriorly (close to the edge of the film medial y) in the lower inner
where cancers are lik ely to de velop, look specifical y for dif fuse quadrant on the right, but these contain lucent centers and are benign.
changes, masses, distor tion, asymmetry, and calcifications. If ou BI-RADS® category 0: need additional imaging evaluation.
focus down with a magnification lens and look specifica y for calci-
Figure 2.11. (Continued) Craniocaudal (C) and mediolateral oblique (D), double spot compression
magnification vi ws.
BI-RADS® category 4: Suspicious abnor mality; biopsy

What do you think?
should be considered. A stereotactically guided needle biopsy is
What BI-RADS® assessment category would you done on the same da y as the magnif ication views. A high-
assign, and what is your recommendation? nuclear-grade ductal carcinoma in situ with central necrosis is
diagnosed on the core biopsy. A 1-cm area of high-nuclear-grade
On the double spot compression magnification vi ws, the morphol- ductal carcinoma in situ with central necrosis and no associated
ogy of the calcifications is much better demonstrate , as is the invasion is described histolo gically on the lumpectom y speci-
extent of the lesion. The calcifications in this cluster are pleomor men. No sentinel lymph node biopsy is done [pTis(DCIS), pNX,
phic, and there are linear forms. Armed with high-quality magnifi pMX; Stage 0].
cation views, our confidence in the li ely diagnosis of ductal carci-
noma in situ is increased significant y, and the need for a biopsy is
easily justified.
PATIENT 9
Figure 2.12. Screening study, 73-year-old woman. Craniocaudal (A) and mediolateral ob lique (B)
views, left breast. No prior films vailable for comparison.
fatty hilum and well-circumscribed margins are demonstrated with

Would you agree with a BI-RADS® assessment
spot compression views, on these screening views no fatty hilum is
category 2: benign finding? apparent and the margins are not well defined. Remember: Ma e
no assumptions. With what degree of certainty can you say this is
There is a mass in the left breast at appro ximately the 3 o’clock
a lymph node? If you are not sure, call the patient back for addi-
position, 4 cm from the left nipple. Did you see it (Fig. 2.12G, H)?
tional evaluation.
What did you think? Good for you, if you are not willing to accept
this as an intramammar y lymph node. Although it may be that a
Figure 2.12. (Continued ) Craniocaudal

D (C) and mediolateral oblique (D) spot com-
pression views, left breast.
A 1-cm spiculated mass is confi med on the spot compression

views. A biopsy is indicated. An ultrasound is done to deter mine
whether the lesion is identified on ultrasound; if it is, ultrasoun
guidance can be used for the core biopsy.
E F
Figure 2.12. (Continued) Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections, left breast.
significance, and our recommendations. Would you now agree with

How would you describe the ultrasound findings?
the assignment of BI-RADS® category 4: suspicious abnormality;
biopsy should be considered.
A vertically oriented, irregular hypoechoic mass with indistinct and
An invasive ductal carcinoma is diagnosed follo wing an ultra-
angular margins, shadowing, and associated distor tion of the sur-
sound-guided core biopsy. A 0.7-cm in vasive ductal carcinoma
rounding tissue is imaged at the 3 o’clock position, 4 cm from the
with tubular features (g rade I) is diagnosed on the lumpectom y
left nipple, cor relating to the e xpected location of the lesion seen
specimen. No metastatic disease is diagnosed in tw o excised sen-
mammographically. With the additional vie ws and the ultrasound
tinel lymph nodes [pT1b, pN0(sn)(i), pMX; Stage I].
we can issue a succinct, definit ve report on the finding, the li ely
Figure 2.12. (Continued) Craniocaudal (G)

and mediolateral oblique (H) views. Box indi-
H cating location of potential mammo graphic
abnormality.
PATIENT 10
B
(B) views.
Figure 2.13. (Continued) Comparison study, craniocaudal (C) and mediolateral oblique (D) views.
Technical factors used for exposures:
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/filte mo/mo mo/rh mo/mo mo/rh mo/mo mo/rh mo/mo mo/rh
What do you think? breath. If, at a gi ven voltage, the resulting amperage is high ( 400
mAs) and the tissue is not adequately exposed, either voltage or com-
Are these mammograms from two different women?
pression (or both) need to be increased. As voltage is increased, the
If they are from the same woman, what is your working resulting amperage (and e xposure time) decreases; as v oltage is
hypothesis? decreased, the resulting amperage (and e xposure time) increases. In
Are there any significant findings in either this woman, the resulting amperages on the cur rent study are w ell
mammogram? below 400 mAs, so the v oltage can be lo wered without sacrificin
adequate exposure of the tissue. As voltage is lowered, contrast is
These mammograms are normal and from the same woman, taken increased, improving overall image quality. Did you notice the lo w
20 months apart. In the inter val, she lost 150 pounds. On the cur- image contrast on the current images? Overall, the images (and par-
rent study (Fig. 2.13A, B), breast size is decreased and parench y- ticularly the fat) look gray, reflecting the poor contrast
mal density is increased, with a concomitant decrease in f at com-
pared with the study from 20 months before (F ig. 2.13C, D). The
changes are bilateral and symmetric. There is no skin or trabecular What is your differential for diffuse breast changes?
thickening. The breasts are significant y thinner, as evidenced by
the millimeters of compression used for e xposure on the cur rent Differential considerations for diffuse changes that are usually uni-
study compared with 20 months before. Gi ven similar kilovoltage lateral, although rarely can be bilateral, include radiation therap y
peaks on both studies, the resulting milliamperage output is consis- effect, inflammato y changes (e.g., mastitis), trauma, ipsilateral
tently lower on the current images. Also, note that rhodium kicked axillary adenopathy with lymphatic obstruction, dialysis shunt in
in for all of the films done on the comparison stud . the ipsilateral ar m with fluid verload, invasive ductal carcinoma
not otherwise specifie , inflammato y carcinoma, invasive lobular
carcinoma, or lymphoma. Invasive lobular carcinoma can lead to
Given the milliamperage output on the current study, increases in breast density and size, or a decrease in breast size (the
what could the technologist have done to improve shrinking breast). Dif ferential considerations for dif fuse changes
image quality? that are usually bilateral, although the y can be unilateral, include
hormone replacement therap y (e.g., estro gen), weight changes,
Image contrast is par tially related to the v oltage used for e xpo- congestive heart failure, renal failure with fluid verload, and supe-
sure. As you increase v oltage, you decrease image contrast. rior vena cava syndrome. Additional rare benign causes include
Optimally, you want to use a high enough voltage to penetrate the granulomatous mastitis, coumadin necrosis, ar teritis, and autoim-
tissue adequately, but not much more than that.At a given voltage, mune disorders (e.g., scleroder ma). Obtaining a thorough histor y,
the resulting amperage also needs to be considered, because this indi- examining the patient, and obtaining an ultrasound are often help-
rectly reflects the length of the xposure. As the amperage is ful in sorting through the differential considerations.
increased, exposure time is increased, and as exposure time increases, BI-RADS® category 1: negative. Next screening mammogram
motion blur may become an issue if the patient is unable to hold her is recommended at age 40.
PATIENT 11
B
ding mass is imaged in tissue projecting on the lower third of the left
What do you think?
breast. If they are available, previous films will be helpful in assess
Is this a normal mammogram, or do you think ing a change and should be requested before calling the patient back
additional evaluation is indicated? for a diagnostic evaluation. In the absence of comparison films, or i
this represents a change w hen comparison is made to se veral
In this patient, by splitting the images (Fig. 2.14C, D) in thirds and sequential mammograms, additional evaluation is indicated.
focusing your attention to the medial por tions of the breasts on the BI-RADS® category 0: need additional imaging evaluation.
craniocaudal (CC) vie ws, a mass is detected mediall y in the left
breast. On the mediolateral ob lique (MLO) views, the cor respon-
Figure 2.14. (Continued ) Craniocaudal (C) and

D mediolateral oblique (D) views with bo xes on the
medial and lower thirds of the breasts, respectively.
Figure 2.14. Craniocaudal (E) and mediolateral oblique (F) spot compression views, left breast.
G Figure 2.14. (Continued) Ultrasound image (G), antiradial (ARAD) projec-

tion, left breast.
oblique (MLO) view are actually above the level of the nipple. In
Where would you place the ultrasound transducer?
this patient, the lesion is in the lower aspect of the upper inner quad-
Be precise. (What clock position? How far back from
rant of the breast at the 9:30 o’clock position (see Fig. 3.6F–I), 4 cm
the nipple?) from the left nipple.
How would you describe the imaging findings? BI-RADS® category 4: suspicious abnor mality, biopsy should
be considered. Rather than just consider it, a biopsy is done.
Spot compression views confi m the presence of a 1-cm mass with An invasive ductal carcinoma is diagnosed follo wing the ultra-
indistinct margins. An irregular, hypoechoic mass with indistinct sound-guided core biopsy. A grade II in vasive ductal carcinoma
and spiculated margins and a par tial echogenic halo is imaged on measuring 1 cm is confi med at the time of the lumpectomy, and the
ultrasound (Fig. 2.14G, H). Although the lesion projects below the sentinel lymph node is ne gative for metastatic disease [pT1b,
level of the nipple on the MLO vie w, be careful in assuming that pN0(sn)(i), pMX; Stage I].
this lesion is in the lo wer inner quadrant of the left breast. Some
lesions that project below the level of the nipple on the mediolateral
Figure 2.14. (Continued) Ultrasound image (H), antiradial (ARAD) projec-

H tion, left breast at the 9:30 o’clock position, 4 cm from the left nipple. A box
delineates the mass.
PATIENT 12
B
What do you think? How would you describe the imaging findings, and
Is this a normal mammogram, or do you think what is indicated?
Spot compression views (not shown) confi m the presence of a 1.5-
A mass is present in the upper cone of tissue on the mediolateral cm spiculated mass at this site. A biopsy is indicated. Ultrasound-
oblique (MLO) view. In many women, this area of tissue on the guided core biopsy is done at the time of the diagnostic study . An
MLO is scalloped. If the tissue in this area rounds of f asymmetri- invasive mammary carcinoma is repor ted histologically. A 1.6-cm
cally, it should raise concer ns about a developing lesion. A spicu- grade I in vasive ductal carcinoma with associated lo w-nuclear-
lated mass is seen laterally in the left craniocaudal view. grade ductal carcinoma with central necrosis is repor ted on the
BI-RADS® category 0: need additional imaging evaluation. lumpectomy specimen. No metastatic disease is diagnosed in tw o
excised sentinel lymph nodes [pT1c, pN0(sn)(i), pMX; Stage I].
Figure 2.15. (Continued) Screening images with a bo x

D indicating the location of the lesion on the left craniocaudal
(C) and mediolateral oblique (D) views.
PATIENT 13
B
the CC views, these are more commonly medial in location but can
What do you think?
also be seen laterally. Additionally, large rodlike calcifications, ori
Is this a normal mammogram, or do you think ented toward the nipple, are noted scattered bilaterally, and a lymph
additional evaluation is indicated? node with a prominent fatty hilum is seen at the edge of the left pec-
toral muscle superiorl y on the left MLO . Following a systematic
Arterial calcifications are present bilateraly. The artery, coursing infe- review of the films, no significant finding is per ved. No additional
riorly at the anterior edge of the right pectoral muscle on the medio- views are indicated.
lateral oblique (MLO) view, is the lateral thoracic ar tery. It is always BI-RADS® category 1: negative. Annual screening mammogra-
seen coursing in the subcutaneous tissue laterally on the craniocaudal phy is recommended (or BI-RADS® cate gory 2: benign findin
(CC) view. The calcified a tery, entering the breast just inferior to the can be used if you describe the arterial or secretory calcifications i
left pectoral muscle on the MLO view and extending toward the nip- your report).
ple, is likely a perforating branch of the internal mammary artery. On
PATIENT 14
Figure 2.17. Screening study, 55-year-old woman. Craniocaudal (A) and

mediolateral oblique (B) views.
What do you think? Is there a potential mass in this patient?

Is this a normal mammogram, or do you think
additional evaluation is indicated? Did you notice the possib le mass in the f atty stripe of tissue
between pectoral muscle and glandular tissue on the left MLO? No
Review the images systematically. Focus your attention on smaller definite abnormality is identified on the CC vi w, but it ma y be
amounts of tissue by splitting the craniocaudal (CC) and mediolat- partially imaged at the edge of the film in the ar posterolateral
eral (MLO) views into thirds (Figs. 2.1 and 2.2). Look for specifi aspect of the left breast. With what degree of confidence can ou
findings, including diffuse changes, masses, distortion, asymmetry, characterize this potential finding, and h w definit ve can you be
and calcifications. R view areas on the mammograms where breast about what the next step should be? How about prior films? If prio
cancers are likely to develop, specifical y, the fatty stripe of tissue films are not available, or this represents an interval change, addi-
between pectoral muscle and glandular tissue on MLO vie ws, the tional imaging may be helpful in deter mining the significance o
superior cone of tissue on MLO views, medial tissue on CC views, this finding
fat–glandular interfaces, and subareolar areas (F ig. 2.3). F ocus
down with a magnification lens, pa ticularly when looking for
small masses, distortion, and clusters of calcifications.
Figure 2.17. (Continued) Mediolateral oblique (C) views, 2 years prior to (B).
The potential abnormality perceived on the cur rent study is not

seen on the prior film. Additional evaluation is indicated.
What additional views will you request? Be specific.
Figure 2.17. (Continued) Right craniocaudal and left cranio-

E caudal exaggerated laterally views (D) and spot compression view,
mediolateral oblique (E) projection.
F G
Figure 2.17. (Continued) 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.
An invasive mammary carcinoma is reported on the ultrasound-

How would you describe the imaging findings?
guided core biopsy. A 0.9-cm, g rade II invasive mammary carci-
What is your recommendation?
noma, apocrine type with associated intermediate-grade ductal car-
cinoma in situ, is diagnosed on the lumpectom y specimen. No
A 1-cm mass is confi med laterally on the exaggerated craniocau-
metastatic disease is diagnosed in three e xcised sentinel l ymph
dal views laterally (XCCL). The margins of the mass are indistinct
nodes [pT1b, pN0(sn)(i), pMX; Stage I].
and partially obscured on the mediolateral ob lique (MLO) spot
Apocrine carcinomas represent less than 1% of all breast cancers
compression view. On ultrasound, a v ertically oriented, irregular
and usually present as a mass that is detected mammo graphically or
mass with indistinct, spiculated mar gins and an echo genic rim is
clinically. The lesions are characterized b y the presence of apocrine
imaged, corresponding to the area of mammo graphic concern.
cells. Some of these cells are characterized b y the presence of an
Associated disruption of Cooper ligaments is noted. With the
eosinophilic granular cytoplasm, often localized to the apical portion
patient supine, this mass is directly on the pectoral fascia and mus-
of cells, and cells with foam y cytoplasm filled with small acuoles.
cle. A developing solid mass with the described imaging features
The presence of gross cystic disease fluid protein, GCDFP-15, char
on a post- or perimenopausal woman requires biopsy.
acterizes both benign and malignant apocrine differentiation.
BI-RADS® category 4: suspicious abnor mality; biopsy should
be considered. Rather than just consider it, a biopsy is done.
Figure 2.17. (Continued) Ultrasound image (H) in transverse (TRS) projec-

tion 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 closel y apposed to the deep pectoral
H fascia (arrowheads). As the patient is imaged and the mass is compressed, mass
effect is noted on the deep pectoral fascia.
PATIENT 15
Figure 2.18. Screening study, 54-year-old woman. Craniocaudal (A) and mediolateral
oblique (B) views.
this is of concern, and it is in a comparab le location on the two pro-

What do you think?
jections, it appears more spread out and less dense on the CC vie w
Is this mammogram normal, possibly abnormal or (Fig. 2D). With what degree of certainty can you say this is normal
definitely abnormal? or abnormal? How would you dictate the repor t? Prior films m y
be helpful. If these are not a vailable, or this represents a change,
Review the images systematicall y. Do y ou see a potential mass? why commit yourself when you can obtain spot compression views
Split the craniocaudal (CC) and mediolateral (MLO) vie ws into and, if needed, correlative physical examination and sonography?
thirds and go back and forth between the right and left breasts (Fig. Depending on the workup, a biopsy may be indicated.
2.18C, D). Does something catch your eye medially and superiorly BI-RADS® category 0: need additional imaging evaluation.
in the CC and MLO views of the right breast, respectively? Although
D Figure 2.18. (Continued) Craniocaudal (C) and mediolateral oblique (D)

views with boxes on the medial and upper thirds of the breasts respectively.
F Figure 2.18. (Continued) Craniocaudal (E) and mediolat-

eral oblique (F) spot compression views, right breast.
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 mammogra-
Puff goes the magic dragon! Nor mal glandular tissue is imaged
phy is recommended.
when focal spot compression is applied in the areas of initial con-
cern. Although the additional mammographic images are definit ve,
PATIENT 16
Figure 2.19. Initial screening study, 38-year-old woman. Craniocaudal (A) and mediolateral ob lique
(B) views.
for calcifications on very screening mammo gram you review,

Any observations?
you are unlikely to miss the rele vant finding in this patient. Di
What BI-RADS® assessment category would you see the cluster of calcifications in the right subareolar area
you assign? Although the appearance of the calcifications is of conce n, with
what degree of confidence can ou characterize these and their
Review the images systematically, looking actively for potential extent? Why not get more information in the form of double spot
lesions. In addition to splitting the craniocaudal (CC) and medi- compression magnification views? If needed , and the patient
olateral oblique (MLO) views into thirds and evaluating the loca- consents, a biopsy can be done at the time of the magnificatio
tions where cancers often de velop, look specifical y for diffuse views.
changes, masses, distor tion, asymmetry, and calcif ications. If BI-RADS® category 0: need additional imaging evaluation.
you focus down with a magnification lens and look specifica y
D
Figure 2.19. Craniocaudal (C) and mediolateral oblique (D) double spot compression magnification vi ws,
right breast.
with high-quality magnification vi ws, our confidence in the diag

nosis and the appropriate recommendation is g reatly enhanced. A
succinct, definit ve report can be generated.
On the double spot compression magnification vi ws, the morphol-
BI-RADS® category 5: Highl y suggestive of malignanc y;
ogy of the calcifications is much better demonstrate , as is the
appropriate action should be taken. Appropriate action, in the form
extent of the lesion. The calcifications in this cluster are pleomor
of an imaging guided biopsy , is undertaken following completion
phic and variable in density. In addition to some of the calcifica
of the magnification vi ws.
tions demonstrating linear orientation, others are linear . The bor-
A high-nuclear-grade ductal carcinoma in situ with central necro-
ders of some of the linear calcifications are i regular and there are
sis is diagnosed on the core samples. This diagnosis is confi med at
associated clefts. This is likely to represent ductal carcinoma in situ
the time of the lumpectomy, and no invasion is identified. No sentine
with central necrosis. There is an associated density such that gross
lymph node biopsy is done [pTis(DCIS), pNX, pMX; Stage 0].
or microscopic invasive ductal carcinoma ma y be present. Armed
PATIENT 17
B
exclude an underlying malignancy. If nor mal tissue is imaged on

What is the primary observation?
spot compression views and ultrasound, and there is no correspon-
ding palpable abnormality on physical examination, no fur ther
A focal area of parench ymal asymmetry is present in the upper
intervention is recommended. Magnetic resonance imaging ma y
outer quadrant of the left breast. It is of comparable size and density
also provide helpful information, particularly in high-risk patients.
and in the same appro ximate distance from the nipple on the tw o
If concerns remain following the diagnostic e valuation, an imag-
projections, but there is f at interspersed in the glandular tissue. In
ing-guided biopsy can be under taken. Fibrosis or pseudoangioma-
most patients, focal parench ymal asymmetry is a nor mal variant.
tous stromal h yperplasia (PASH) is often the diagnosis on core
Progressive development of focal parenchymal asymmetry can be
biopsies done through these areas.
benign, presumably related to hormonal variations.
What additional information would you like? What is your differential at this point?
Differential considerations include normal variant, hormone replace-

A good history is important. Has the patient had any breast surgery
ment therapy effect, asymmetry secondary to prior surgical excision
(e.g., a comparable area of tissue e xcised from the right breast, or
of the cor responding tissue in the right breast, focal f ibrosis,
does this finding reflect at necrosis postsurgery)? Is there any his-
pseudoangiomatous stromal hyperplasia (PASH), posttraumatic
tory of trauma to this site (e.g., hematoma)? Estro gen use?
changes (evolving hematoma; f at necrosis), mastitis, fibroadeno
Presumably, if the patient had any focal tenderness, erythema, skin
lipoma (hamartoma), invasive ductal carcinoma not otherwise speci-
dimpling, or discoloration limited to this site, she would have been
fie , invasive lobular carcinoma, and lymphoma.
scheduled for a diagnostic e valuation or your technologist would
In this patient, the area is unchanged from prior studies (not shown).
have indicated this on the woman’s history sheet.
This mammogram can be categorized as BI-RADS® category 1:
Comparison with prior studies is critical. If the area of focal
negative. BI-RADS® cate gory 2: benign finding is used if th
parenchymal asymmetry represents a change, or if no prior studies
observation is described in the report. Annual screening mammog-
are available for comparison, spot compression vie ws and ultra-
raphy is recommended.
sound with cor relative physical examination are recommended to
PATIENT 18
B
cone of tissue on MLO vie ws, medial tissue on CC vie ws, the
What do you think?
fat–glandular interfaces, and the subareolar areas (F ig. 2.3). Focus
Is this a normal mammogram, or do you think down with a magnification lens, pa ticularly when looking for small
additional evaluation is indicated? masses, distortion, and clusters of calcifications. Is there a potentia
mass in this patient? Did y ou notice the right subareolar area? With
Review the images systematically. Look for specific findings, inclu what degree of confidence can ou characterize this potential finding
ing diffuse changes, masses, distor tion, asymmetry, and calcifica and how definit ve can you be in determining its significance? Prio
tions. Focus your attention on smaller amounts of tissue b y splitting films will be helpful, as will a sur gical history. If prior films are no
the craniocaudal (CC) and mediolateral ob lique (MLO) views into available (and the patient has no history of surgery), additional imag-
thirds (Figs. 2.1 and 2.2). Re view those areas w here breast cancers ing is needed to determine the significance of this finding
commonly develop, specifical y the f atty stripe of tissue betw een BI-RADS® category 0: need additional imaging evaluation.
pectoral muscle and glandular tissue on MLO vie ws, the superior
D Figure 2.21. (Continued ) Craniocaudal (C) and mediolateral

oblique (D) spot compression views, right subareolar area.
E F
Figure 2.21. (Continued) Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections, right subareolar area.
as an unf avorable prognostic finding, pa ticularly in node-negative

patients treated with either mastectomy or lumpectomy. The signifi
recommendation?
cance in patients with positive axillary lymph nodes (as in our current
patient) is not clear. Extracapsular extension has also been described
Spot compression views of the right subareolar area confim the pres-
as an unfavorable prognostic factor.
ence of a 2-cm mass. The patient has no histor y of previous breast
surgery. An irregular, vertically oriented, hypoechoic mass with spic-
ulated and angular mar gins and associated shado wing is imaged in What is the single most important prognostic factor in
the right subareolar area on ultrasound. These findings, in a 65- ear-
women with an invasive breast cancer diagnosis?
old woman with no history of surgery at this site, require biopsy. The
additional views are helpful in estab lishing the presence of a lesion
The presence of metastatic disease in axillary lymph nodes is the sin-
and demonstrating the morphologic features of the lesion.
gle most important prognostic factor, and there is a direct correlation
BI-RADS® category 4: Suspicious abnor mality; biopsy should
between the number of positi ve lymph nodes and disease-free sur-
be considered.
vival, as well as mor tality. In patients with tumors 2 cm in size,
Rather than just consider it, a biopsy is done.An invasive lobular
Carter et al. repor ted overall 5-year survival rates of 96.3% in
carcinoma is diagnosed, following ultrasound-guided core biopsies.
patients with negative lymph nodes, 87.4% for patients with one to
A 2.2-cm invasive lobular carcinoma is confi med at the time of the
three positive axillary lymph nodes, and 66% for patients with four or
lumpectomy. Lymphovascular space in volvement is present and
more positive axillary lymph nodes. In the sixth edition of the
metastatic disease is found in the sentinel l ymph node, so an axil-
American Joint Committee on Cancer (AJCC) Staging Manual, the
lary dissection is under taken. Three of 12 l ymph nodes ha ve
pathologic status of node-positive patients has been revised to reflec
metastatic disease with extracapsular extension in one of the three
the prognostic significance of the number of posit ve lymph nodes:
positive lymph nodes (pT2, pN1a, pMX; Stage IIB).
pN1a for patients with one to three positi ve axillary lymph nodes;
pN2a for patients with four to nine positive axillary lymph nodes, and
What is the significance of lymphovascular space pN3a for patients with 10 or more positive axillary lymph nodes.
involvement?
Lymphovascular space involvement is described in appro ximately

15% of patients with invasive ductal carcinoma. It has been described
PATIENT 19
(B) views.
for motion, you will notice b lurring of tissue anteriorl y; an addi-

What do you think?
tional sign of suboptimal compression. Blur ring can tomo gram
Would you agree with a BI-RADS® assessment small spiculated masses and clusters of calcification o f the image;
category 1 or 2 for this mammogram? however, it often goes undetected because w e do not specifical y
assess and insist on high image quality . As with subtle findings o
Did you review this study for technical adequac y as your starting breast cancer, blurring will go undetected unless you recognize how
point? Positioning and compression are not optimal. There is insuf- much it can limit your ability to perceive important lesions and you
ficient pectoral muscle on the mediolateral ob lique (MLO) views. focus your attention on looking for it before attempting to look for
Although it is thick in the axillar y region, pectoral muscle should potential lesions.
be seen to the level of the nipple and it should have a convex ante-
rior margin. Given the triangular shape of the muscle in this patient,
several things went wrong during positioning. It is lik ely that an Did you notice anything else, and what would you like
incorrect angle of ob liquity was selected, the muscles w ere not to do next?
relaxed, and the breasts were not adequately mobilized medially (or
if they were, the patient pulled out during positioning). How about the mass in the lateral aspect of the left breast? On the
On the craniocaudal (CC) views, a significant amount of posterio MLO view, it is likely to be on the upper cone of tissue.As a further
tissue is excluded from the images. In deter mining whether an ade- indication of how much tissue is missing on the CC vie w, notice
quate amount of tissue has been included on the CC vie ws, look for the relationship of this lesion to the edge of the film on the CC an
pectoral muscle posteriorl y or for clea vage medially. If neither of the MLO view. Momentarily you might think that what you see on
these is seen, measure the posterior nipple line (PNL) on the MLO the CC view is not what you see on the MLO view; however, if you
(and remember, in this patient, positioning on the MLO views is not measure back from the nipple, the lesion is at appro ximately the
optimal, so the PNL measurement is not an optimal measure of the same distance from the nipple. Based on the technical limitations of
amount of tissue this patient has) and compare it to that measured on the study alone, the patient needs to be called back. With respect to
the CC views (Fig. 2.4E, F). The PNL measurement on the CC view the mass noted in the left breast, comparison studies ma y be help-
should be within 1 cm of that measured on the MLO view. It is not in ful. If the mass is decreasing in size, or has been pre viously evalu-
this patient. Also, notice the relationship of the mass to the edge of ated, it may not require additional e valuation at this time. If there
the film on the MLO vi w and compare it to that seen on the CC view. are no prior studies, or these are unavailable, or if this represents an
There is inadequate separation of tissue, particularly on the MLO interval change, additional evaluation is indicated.
views, consistent with suboptimal compression. Additionally, if BI-RADS® category 0: need additional imaging evaluation.
you evaluate the left MLO and specifical y send your eyes looking
Figure 2.22. (Continued) Craniocaudal (C)

and mediolateral oblique (D) spot compression
D views, left breast. Additional views to address
described technical limitations are not shown.
noma), papilloma, focal fibrosis, pseudoangiomatous stromal yper-

plasia (PASH), sclerosing adenosis, ph yllodes tumor, or a g ranular
In a 40-year-old woman, what differential would you cell tumor. In the malignant category, one would consider an invasive
consider based on the mammographic findings alone? ductal carcinoma not otherwise specifie , medullary carcinoma,
although possible mucinous and papillar y carcinomas are usuall y
A 1-cm mass with indistinct mar gins is confi med on the spot com- diagnosed in postmenopausal women, a metastatic lesion (in patients
pression views. At this point, in a 40-y ear-old woman, benign differ- with a known malignancy), and adenoid c ystic carcinoma. Invasive
ential considerations are e xtensive and include an intramammar y lobular carcinomas do not typically present as a round-oval mass.
lymph node, cyst, fibroadenoma (compl x fibroadenoma, tubular ade
E F
Figure 2.22. (Continued) Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections, upper outer quadrant, left breast.

How would you describe the ultrasound finding?
be considered.
A biopsy is done. An invasive ductal carcinoma is diagnosed, fol-
lowing an ultrasound-guided core biopsy. A 0.8-cm grade III inva-
An irregular, vertically oriented, hypoechoic mass with angular
sive ductal carcinoma is diagnosed following the lumpectomy, and
and spiculated margins is imaged at the 2 o’clock position, 6 cm
two excised sentinel lymph nodes are ne gative for metastatic dis-
from the left nipple. Given the indistinct margins mammograph-
ease [pT1b, pN0(sn)(i), pMX; Stage I].
ically, and the sonographic appearance of this lesion, a biopsy is
indicated.
PATIENT 20
uation is beneficial in better characterizing the xtent of the lesion

What do you think, and what BI-RADS® assessment
and the morphology of the calcifications.
category would you assign? BI-RADS® category 0: need additional imaging evaluation.
A round mass with an adjacent area of calcifications is identified
the left breast. Although a malignancy is suspected, additional eval-
Figure 2.23. (Continued) Craniocaudal (C) and mediolateral oblique (D) double spot compression magnification vi ws, left breast.
round calcifications demonstrating a linear (branching) orientatio

extend for approximately 3 cm anterior to the mass.
Double spot compression views demonstrate a 1-cm round mass with
microlobulated, indistinct and spiculated mar gins. Predominantly
E F
Figure 2.23. (Continued) Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections in the upper inner quadrant of the left breast.
ductal carcinoma in situ (calcifications). An invasive mammary car-

cinoma is diagnosed following an ultrasound-guided core biopsy of
the mass. As is our routine on patients with a breast cancer diagno-
On ultrasound, a round mass with indistinct margins, an echogenic
sis following an imaging-guided biopsy, magnetic resonance imag-
halo, minimal posterior enhancement, and disruption of Cooper
ing is obtained. This further assesses the ipsilateral breast for unsus-
ligaments is imaged at the 10 o’clock position, 8 cm from the left
pected multifocal or multicentric disease, as well as the status of the
nipple. Did you notice the calcification in the mass mamm graphi-
contralateral breast.
cally and on ultrasound? The calcification noted in the mass mam
mographically on both projections is also identified on the ultra
sound (Fig. 2.23G). Ho wever, the linearl y oriented calcification
cannot be identified with ce tainty 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 path g-

nomonic for an invasive ductal carcinoma (mass) with an associated
H I
K
J
Figure 2.23. (Continued) 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 tab letop position as sho wn in (H), 10 minutes following contrast
administration.
and heterogeneous enhancement. Ductal enhancement is present,

corresponding to the area of calcifications seen mamm graphically.
No additional lesions are noted in the left breast, and no masses or
The dynamic sequence demonstrates a mass with rapid w ash-in
other abnormal areas of enhancement are seen in the right breast
and wash-out of contrast, characteristic of malignant lesions.
(images not shown).
Morphologically, this is an ir regular mass with ir regular margins
G L
Figure 2.23. (Continued) 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 radi graphy unit.
At the time of the preoperati ve wire localization, the lesion is the specimen to mark the location of the lesion(s) for the pathologist.
bracketed with two wires to assure complete excision of the lesion Portions of the localizing wires are seen on the radio graph (arrows).
(i.e., the mass and all calcifications). One of the wires is used t Also noted is one of se veral markers placed by the surgeon intraop-
skewer the mass and a second is placed anteriorly through the lead- eratively to indicate the different margins, thereby orienting the spec-
ing edge of the calcifications.The excised tissue is placed in a plas- imen for the patholo gist. The marker seen here is the skin mark er;
tic container (a Dubin device) and an alphanumeric grid is used to additional markers include caudal, cranial, medial, and lateral mark-
compress the tissue. A radiograph of the specimen is taken to assure ers. In addition to these markers used by the surgeon, the pathologist
excision of the localized lesion(s). In this patient, the mass is seen inks the margins so that e xtension of tumor to the mar gins can be
at the edge of the image (Fig. 2.23L, arrowhead) and the calcifica assessed at the time of histologic evaluation. If tumor is seen extend-
tions extending away from the mass are also present. The apparent ing to the margins, re-excision is usually indicated.
proximity of the mass to one of the mar gins on the radio graph is A 1.2-cm invasive mammary carcinoma with apocrine features is
discussed with the surgeon so that additional tissue may be taken. reported histologically. Associated high-nuclear-grade ductal carci-
The Dubin device provides an alphanumeric grid (letters partially noma in situ with central necrosis is present. The sentinel lymph
seen) with corresponding “holes” so that pins can be placed through node is normal [pT1c, pN0(sn)(i), pMX; Stage I].
PATIENT 21
B Figure 2.24. Screening study, 44-year-old woman.

pattern on the right mediolateral ob lique (MLO) vie w, and skin

What observations can you make on this patient’s
thickening inferiorly on the left MLO. These findings are commo
mammogram, and what conclusion can you draw? in women following reduction mammoplasty. From a review of her
What recommendation would you make? history form, she has had a reduction mammoplasty. No masses or
malignant type calcifications are present
Pertinent observations include fibrotic bands in the subareolar area BI-RADS® category 1: negative. Annual screening mammogra-
on the craniocaudal vie ws, islands of nonanatomicall y distributed phy is recommended.
tissue bilaterally, inferior displacement of tissue with a s wirling
PATIENT 22
B
ble presence of dif fuse changes. The trabecular markings are

What do you think and what would you like to do next?
increased diffusely, thickened, and extend close to the chest w all.
For diffuse changes to be appreciated , particularly when they are
In reviewing this mammogram, did you consider the possibility of
bilateral, you need to consider them specifical y as a possibility;
a diffuse abnormality? Remember to initially sit back and look at
otherwise they may go undetected.
the study from a distance. Assess technical adequacy and the possi-
D
Figure 2.25. Craniocaudal (C) and mediolateral oblique (D) views, 3 years before those shown above.
would expect, peak kilo voltages and milliamperage output are

What do you think a comparison of technical factors
higher and the breasts are less compressib le on the cur rent study
would show? compared with the study from 3 y ears earlier. Reviewing the
In addition to the comparison studies, what else might patient’s history form should be helpful as you consider the differ-
help you with the differential? ential: The patient is shor t of breath (as detailed b y the technolo-
gist), is on diuretics, and has a histor y of congestive heart failure
The initial perception of a diffuse abnormality can be confi med by (CHF). In this patient, the described findings are related to CH
comparing present to prior mammograms (Fig. 2.25C, D). In com- and, as the CHF is treated, you can expect significant impr vements
paring the two studies, consider the o verall density of the breast in the mammographic findings
parenchyma and the prominence of the trabecular patter n. As you
E Figure 2.25. (Continued) Ultrasound image (E) of the left breast at the 9
o’clock position.
Although an ultrasound is not indicated in this patient, y ou can increases in breast density and size, or a decrease in breast size (the
expect to see skin thickening, increased echogenicity of the tissue, shrinking breast). Dif ferential considerations for dif fuse changes
and reticulation consistent with edema. that are usually bilateral, although the y can be unilateral, include
hormone replacement therap y (e.g., estro gen), weight changes,
congestive heart failure, renal failure with fluid verload, and supe-
What is your differential for diffuse breast changes? rior vena cava syndrome. Additional rare benign causes include
granulomatous mastitis, coumadin necrosis, ar teritis, and autoim-
Differential considerations for diffuse changes that are usually uni- mune disorders (e.g., scleroder ma). Obtaining a thorough histor y,
lateral, although rarely can be bilateral, include radiation therap y examining the patient, and obtaining an ultrasound are often help-
effect, inflammato y changes (e.g., mastitis), trauma, ipsilateral ful in sorting through the differential considerations.
axillary adenopathy with lymphatic obstruction, dialysis shunt in BI-RADS® category 2: benign finding. Annual screening mam-
the ipsilateral ar m with fluid verload, invasive ductal carcinoma mography is recommended.
PATIENT 23
B
uation. Lymph nodes are seen projecting superimposed on the left

What do you think, and would you like to do anything
pectoral muscle.
else?
There are scattered densities in an otherwise predominantl y fatty Did you notice the uneven exposure on the
pattern. Is it possible that any one of these densities represents an craniocaudal views posteromedially (more prominent
early malignancy? This is what makes what we do a challenge, on the right)? What does this reflect?
particularly because it w ould not be ideal to call back all w omen
with this mammographic appearance. Comparison with prior stud- This usually reflects suboptimal compression with an associated ai
ies dating back several years is indicated in women with this type of pocket. Consequently, evaluate the tissue in these areas carefull y
parenchymal pattern. If an y of these areas represents a change, for blur, because the compression of the tissue in these areas is
additional evaluation is indicated; however, if the findings are sta probably not optimal.
ble, annual mammography is recommended. Arterial calcifications BI-RADS® category 2: benign finding. Annual screening mam-
noted bilaterally, are most lik ely perforating branches from the mography is recommended.
internal mammary artery. There are also large rodlike calcification
present bilaterally; these are benign and require no additional eval-
PATIENT 24
Figure 2.27. Screening study, 59-year-

B old woman. Craniocaudal (A) and medio-
lateral oblique (B) views.
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. (Continued) Mediolateral oblique (C) views, 1 year prior to (B), and mediolateral oblique (D) views, 6 years prior
to those of (B).
Remember: make no assumptions. When you make assumptions,

you pigeonhole yourself. Logically, how can we establish if this
When screening studies are hung on the multiviewer, lesion is medial, central, or lateral in location? A 90-degree lateral
what is the routine for which comparison films view can help us determine the location of this lesion. If the lesion
to hang? moves up in going from mediolateral ob lique (MLO) to lateral
view, the lesion is in the medial aspect of the breast. If the lesion
A micromark clip is present in the upper outer quadrant of the left moves down in going from MLO to lateral view, the lesion is in the
breast, consistent with the histor y of a prior stereotactiall y guided lateral aspect of the breast; and if the lesion does not shift in posi-
biopsy (Fig. 2.27E). Arterial calcifications are noted bilateral y, as tion, it is central in location. Alternatively, line up lateral, MLO ,
are several benign-appearing l ymph nodes superimposed on the and CC views with the nipple on the same horizontal plane for the
pectoral muscles. Ho wever, with careful e valuation, the mass three views and draw a line connecting the lesion on the lateral and
superimposed on the lower aspect of the left pectoral muscle does MLO views and extend it into the CC vie w. On the CC vie w, the
not have an identifia le fatty hilum (Fig. 2.27E). When compared lesion can be found some where along the course of the resulting
with prior studies, this mass has increased in size and the change in line. You can localize the lesion more precisely by measuring how
size is best appreciated w hen comparison is made to the earliest far posteriorly the lesion is in the breast with respect to the nipple
study available (Fig. 2.27D). Subtle changes are more dif ficult to (Fig. 2.27F).
appreciate from one year to the ne xt, but may be readily apparent As you can see from the ultrasound (Fig. 2.27G), this lesion is in
when an earlier study is used. Consequentl y, when the screening the upper, inner quadrant of the left breast at the 11 o’clock posi-
board is hung, we use the study from 2 years previous to the current tion, posteriorly (Z3) sitting on the pectoral muscle.An oval, nearly
study. If the patient has other studies, these are also immediatel y isoechoic mass with parallel orientation, indistinct mar gins, and
available in the patient’s jacket for our review. It is common for us some shadowing as well as straightening and thickening of Cooper
to review several prior studies, including the earliest study available ligaments is imaged on ultrasound.
in the patient’s jacket, particularly before calling a patient back. BI-RADS® category 4: suspicious abnor mality; biopsy should
be considered.
An invasive ductal carcinoma is diagnosed follo wing the ultra-
On the craniocaudal (CC) view, where would you
sound-guided core biopsy. A 1.2-cm tubular carcinoma is diag-
expect to find this lesion and what views do you want nosed on the lumpectomy specimen. No metastatic disease is diag-
your technologist to do to image this lesion in the nosed in four e xcised sentinel lymph nodes [pT1c, pN0(sn)(i ),
CC projection? pMX; Stage I]. The well-differentiated nature of this lesion could
have been suggested based on the relati vely slow growth of the
Obviously, this will depend on the location of the lesion; however, mass compared with 1 and 6 years previously.
this is not kno wn because the lesion is not seen on the CC vie w.
Did you assume this lesion is in the lateral aspect of the left breast?
Figure 2.27. (Continued) Mediolateral

oblique (E) views. Micromark clip
(arrow) is seen in the left breast consistent
with a prior stereotacticall y guided, vac-
uum-assisted biopsy for microcalcifica
E tions. The potential percei ved lesion is
within the box.
Figure 2.27. Diagram (F) illustrating a triangulation method described by Sickles to localize lesions on or thogonal 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 approxi-
mate the location of the lesion along the course of the line.
G Figure 2.27. Ultrasound image (G) in the radial (RAD) projection of the
lesion identified posterior y (Z3) at the 11 o’clock position of the left breast.
PATIENT 25
the radio-opaque linear mark er used on the right craniocaudal

What are the pertinent observations?
view at the site of a prior excisional biopsy? Did you notice that
the right breast is slightl y smaller than the left? The patient has
There is global parench ymal asymmetry in the left breast.
had a prior biopsy in the upper outer quadrant of the right breast
Establishing the presence of global parench ymal asymmetry
with resulting asymmetry of the remaining tissue on the left. Did
requires comparison with the contralateral side. A greater volume
you notice the suboptimal positioning on the mediolateral
of tissue is present in the left breast compared to the same area in
oblique views? An inadequate amount of pectoral muscle is
the right breast. As defined in the ourth Edition of BI-RADS®,
included in the images.
global asymmetry should in volve 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 How often do you see mammographic changes
woman as a nor mal variant. No mass or distor tion is noted in the following an excisional biopsy? And what are the
area of increased tissue on the right. The tissue in this area is scal-
possible changes?
loped and contains associated areas of f atty lobulation. Abnormal,
asymmetric changes may be the result of chest w all trauma (e.g.,
We do not routinely use scar markers on screening studies because
burns), congenital abnor malities (e.g., Poland syndrome), or sur-
no perceivable abnormality is apparent in more than 50% of women
gery when the cor responding area of tissue in the contralateral
following a breast biopsy. Additionally, in those w omen in whom
breast has been e xcised. Invasive ductal carcinomas can present
postoperative changes are noted, they can usually be characterized
with global areas of parenchymal asymmetry, but these are usually
as such without the use of scar mark ers. Placing markers on the
clinically apparent and readily palpable. Invasive lobular carcinoma
breast is time-consuming, can be distracting at the time of inter-
can also present with global areas of parench ymal asymmetry and
pretation, and is relatively costly. Changes that can be seen follow-
progressive changes in breast size (either increases or decreases);
ing an e xcisional biopsy include a decrease in the size of the
palpable findings m y be present, but they are often more subtle in
affected breast, localized skin thickening and retraction, architec-
patients with invasive lobular carcinomas. Rarel y, lymphoma can
tural distortion, a spiculated or mix ed-density mass, oil c yst(s),
present with diffuse, asymmetric involvement of one breast.
dystrophic calcifications, and areas of focal or global parenc ymal
asymmetry in the contralateral breast, as demonstrated with this
patient’s mammogram.
Based on your observations, what is your working BI-RADS® category 1: negative, unless this is the first study fol
hypothesis for this patient and what BI-RADS® lowing the biopsy, in which case BI-RADS® cate gory 2: benign
category would you use? finding, can be used if the obser vation is described in the repor t.
Annual screening mammography is recommended.
In this w oman, you can estab lish the iatro genic cause of the
asymmetry by making all pertinent observations. Did you notice
PATIENT 26
B
What do you think? What is the goal when viewing and interpreting
Do you see a potential lesion? screening mammograms, and why place a high
emphasis on additional imaging evaluations?
Review the images systematicall y. Do you see a potential mass?
Split the craniocaudal and mediolateral ob lique views into thirds On screening studies our goal is to detect potential abnormalities.
to focus your attention as you go back and forth between the right We make no ef fort to characterize potential or tr ue lesions on
and left breasts. Does something catch y our eye in the left breast screening studies. Additional evaluations increase our confidenc
anterolaterally? With what degree of certainty can you say this is in appropriate recommendations and often point to the proper diag-
normal or abnormal? How would you dictate the report? Why not nosis. They also provide us with the opportunity to establish a rap-
get additional infor mation by comparing the cur rent study with port with our patients and complete w orkups, including imaging
prior films, and depending on hat the comparison shows, obtain- guided biopsies, w hen indicated. Definit ve and directi ve reports
ing spot compression views, correlative physical examination, and are generated. Consequently, the only BI-RADS® assessment cate-
sonography? Depending on what is found on the workup, a biopsy gories we use on our screening studies are category 1: negative, cat-
may be indicated. egory 2: benign finding(s), and cat gory 0: need additional imaging
BI-RADS® category 0: need additional imaging evaluation. evaluation or need prior mammograms for comparison.
Figure 2.29. (Continued) Craniocaudal (C) and mediolateral

D oblique (D) focusing on the mid aspect of the breasts.
Do you see a possible mass in the left subareolar

area?
F
Figure 2.29. (Continued) Craniocaudal (E) and mediolateral oblique (F) spot compression views.
recommendations confident y and to dictate a succinct, definit ve,

Do the spot compression views help you?
and directive report (in essence, a 2-cm, spiculated, irregular mass is
With what degree of certainty can you now say there is confi med at the 2 o’clock position of the left breast 1 cm from the
a significant abnormality in the left breast? nipple. Biopsy is indicated. An imaging-guided biopsy is undertaken
and reported separately).
A 2-cm, irregular, spiculated mass is confi med on the spot compres- BI-RADS® category 4: suspicious finding; biopsy is indicated. An
sion views. The ultrasound demonstrates a h ypoechoic, intensely ultrasound-guided core biopsy is done at the time of the diagnosticeval-
shadowing mass with v ertical (i.e., not parallel or taller than wide) uation. An invasive mammary carcinoma, thought to be either an inva-
orientation and spiculation. If there is no histor y of surgery, signifi sive ductal carcinoma with lobular features or an invasive lobular car-
cant trauma, or mastitis at this site, this finding requires a biops , cinoma, is repor ted on the core samples. A 2.3-cm invasive lobular
which can be readily, easily, and safely undertaken at the time of the carcinoma is reported histologically following the lumpectomy. The
diagnostic evaluation using ultrasound guidance. The information sentinel lymph node is normal [pT2, pN0(sn)(i), pMX; Stage IIA].
provided by the additional vie ws is critical in enab ling us to mak e
H
G
Figure 2.29. (Continued) Ultrasound images in radial (RAD) (G) and antiradial (ARAD) (H) projections, left breast at the 2 o’clock position, anteriorl y
(Z1).
PATIENT 27
A B
Figure 2.30. Screening study, 62-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, right breast.
from an area of density in the upper inner quadrant of the right

Any observations?
breast. If there is no history of surgery at this site, additional evalu-
Do you think additional views are indicated? ation is indicated.
In reviewing this mammo gram, consider the f at–glandular inter-
faces and medial tissue. Straight lines can be seen radiating out
C D
Figure 2.30. (Continued) Craniocaudal (C) and mediolateral oblique (D) views, right breast. The potential lesion is enclosed in the box.
Figure 2.30. (Continued) Spot compression view (E), right craniocaudal projection.
A spiculated mass is confi med with the spot compression vie w.

Based on the mammographic findings, a biopsy is indicated.
F G
Figure 2.30. (Continued) Ultrasound images in longitudinal (LON) (F) and transverse (TRS) (G) orientations, right breast.
How would you describe the ultrasound findings? What is the reported incidence of axillary nodal
metastasis in patients with T1 tumors, and what factors
A 1.5-cm irregular mass with indistinct and angular margins, shad- have been suggested as predictors for nodal
owing, and associated disr uption of the nor mal tissue planes (dis- involvement?
tortion) is imaged at 1 o’clock, 8 cm from the right nipple, cor re-
sponding to the area of mammographic concern. The reported incidence of axillary nodal metastasis in patients with
BI-RADS® category 4: suspicious abnor mality; biopsy should T1 tumors (2-cm-sized tumors or smaller) ranges from 6% to 36%.
be considered. An invasive ductal carcinoma is repor ted histologi- Predictors of axillar y lymph node metastasis in patients with T1
cally following an ultrasound-guided biopsy. A 2-cm grade I, inva- tumors include tumor size, lymphovascular space involvement, and
sive ductal carcinoma is repor ted on the lumpectom y specimen. the histological grade of the lesion (e.g., in one repor t, 26.7% of
Metastatic disease is diagnosed in one of fi e excised axillary patients with g rade I, T1c tumors had metastatic disease to the
lymph nodes (pT1c, pN1, pMX; Stage IIA). axilla, compared with 35.7% of patients with grade III, T1c tumors).
PATIENT 28

Are there any findings in the right breast? alized laterally on the right craniocaudal vie w. No abnor mality is
Are there any findings in the left breast? appreciated in the left breast. Additional evaluation with magnifica
tion views is indicated on the right.
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 visu-
Figure 2.31. (Continued) Double spot compression magnification vi ws, craniocaudal projection, exaggerated laterally (XCCL) (C).
A cluster of pleomor phic calcifications of ariable density, Appropriate action, in the for m of a stereotactiall y guided
imaged on the e xaggerated craniocaudal vie ws laterally (XCCL) biopsy, is taken. A high-nuclear-grade ductal carcinoma with cen-
magnification view, is shown here. Some of the calcifications ar tral necrosis is diagnosed following the core biopsy. As with all of
linear and some demonstrate linear orientation.This is likely to rep- our patients diagnosed with breast cancer , magnetic resonance
resent a ductal carcinoma in situ with central necrosis. imaging (MRI) is undertaken to evaluate for the presence of multi-
BI-RADS® category 5: Highl y suspicious of malignanc y; focal or multicentric disease in the ipsilateral breast and to assess
appropriate action should be taken. the contralateral breast.
D E
F G
Figure 2.31. T1-weighted, sagittal image (D), right breast, precontrast, and T1-weighted, sagittal image (E), right breast, 1 minute following intravenous
bolus of gadolinium, same tab letop position as sho wn 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).
mass, characterized by rapid wash-in and wash-out of contrast, is

imaged in the left breast. The patient is called back follo wing the
MRI for ultrasound evaluation of the left breast. Based on the MR
A focus of enhancement is noted posteriorly in the right breast, cor-
images (i.e., slice thickness and relationship of lesion to nipple), the
responding to the area of ductal carcinoma in situ detected mam-
expected location of the lesion can be appro ximated prior to the
mographically. Kinetically, there is rapid w ash-in and wash-out of
ultrasound.
contrast, consistent with a malignant process. Une xpectedly, a
H Figure 2.31. (Continued) Ultrasound image (H), lower inner quadrant, left
breast.
characterizing the extent of the disease and directing appropriate

What do you think, and what is your recommendation?
surgical management in some patients. Women with multicentric
lesions confi med to be either intraductal or invasive disease may
An irregular 1-cm mass with indistinct mar gins is identified at th
be more appropriatel y managed with a mastectom y, and those
7 o’clock position, 2 cm from the left nipple.
with more extensive or multifocal disease may require wider exci-
sions than initially planned. In the 5% to 6% of women identifie
be considered.
with synchronous contralateral cancers, bilateral procedures are
An invasive mammary carcinoma is diagnosed follo wing ultra-
indicated.
sound-guided core biopsy.
For patients with MRI-detected lesions, the location of the lesion
A high-nuclear-grade ductal carcinoma in situ, associated with
is approximated based on the MRI and a tar geted ultrasound is
necrosis and calcifications measuring 2 cm in size, is conf med fol-
done. If the lesion is identifie , an ultrasound-guided biopsy can be
lowing a lumpectomy on the right. Three excised sentinel lymph
done; otherwise, MR-guided biopsy, clip placement, or wire local-
nodes are nor mal [pTis(DCIS), pN0(sn)(i), pMX; Stage 0]. A
ization may be indicated.
grade I invasive ductal carcinoma measuring 1 cm is confi med fol-
lowing 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
PATIENT 29
B
variable. In some women, fluid collections m y develop at the site

What do you think?
of the implants; in others, por tions of the capsule ma y be seen as
curvilinear densities in the central aspect of the breasts posteriorly.
Bilateral, symmetric spiculated masses are present with associated
Dense calcifications (dystrophic) m y occur. Rarely, spiculated
distortion. What could generate symmetric, almost identical finding
masses, presumably reflecting at necrosis, may be present (as in
in this location? What specific question ould you ask the patient?
this woman). Alternatively, the mammogram may be nor mal fol-
lowing implant removal.
How about, did she have implants and were they BI-RADS® category 1: ne gative. BI-RADS® cate gory 2:
removed? benign findings, is used if the obse vations are described in the
report. Annual screening mammography is recommended.
Yes, she has had implants, and the y have been remo ved.
Mammographically, the findings foll wing implant remo val are
PATIENT 30
B
exclude an underlying malignancy. If nor mal tissue is imaged on

What do you think, and what additional information
spot compression views and ultrasound, and there is no correspon-
would you like? ding palpable abnormality on ph ysical examination, no fur ther
intervention is recommended. Magnetic resonance imaging ma y
A focal area of parenchymal asymmetry is present in the upper cen-
also provide helpful information, particularly in high-risk patients
tral aspect of the left breast. It is in the same appro ximate distance
in whom no definite mass is palpated but there is thic ening or per-
from the nipple on both projections; ho wever, it appears more
sistent concerns discerned during the ph ysical examination at the
spread out on the craniocaudal (CC) view. On the CC view, this area
site of the asymmetry. If concerns remain following the diagnostic
lacks the convex borders that are associated with most masses, and
evaluation, an imaging-guided biopsy can be undertaken.
there is f at interspersed in the glandular tissue. In most patients,
Fibrosis or pseudoangiomatous stromal h yperplasia (PASH) is
focal parenchymal asymmetry is a normal variant.
often the diagnosis on core biopsies done through these areas.
A good history is important. Has the patient had any breast sur-
gery (e.g., a comparab le area of tissue e xcised from the right
breast), or does this finding reflect at necrosis postsurgery at this What is the differential diagnosis?
site in the left breast? Is there an y history of trauma to this site
(e.g., hematoma)? Estrogen use? Presumably, if the patient had any Differential considerations include nor mal variant, hormone
focal tenderness, erythema, skin dimpling, or discoloration limited replacement therapy effect, asymmetry secondary to prior surgical
to this site, she would have been scheduled for a diagnostic evalu- excision of the corresponding tissue in the right breast, focal fibro
ation or y our technologist would have indicated this on the sis, pseudoangiomatous stromal h yperplasia (PASH), postsurgical
woman’s history sheet. or traumatic changes (e volving hematoma; fat necrosis), mastitis,
fibroadenolipoma (hamartoma), invasive ductal carcinoma not oth-
What else would be helpful? erwise specifie , invasive lobular carcinoma, and lymphoma.
This area is unchanged from prior studies (not shown).
Comparison with prior studies is critical. If the area of focal BI-RADS® category 1: negative. Annual screening mammogra-
parenchymal asymmetry represents a change, or if no prior studies phy is recommended.
are available for comparison, spot compression vie ws and ultra-
sound with cor relative physical examination are under taken to
PATIENT 31
Figure 2.34. Screening study, 74-

year-old woman. Craniocaudal (A)
B and mediolateral ob lique (B) views.
Metallic BB on skin lesion, left breast.
medial quadrants on the craniocaudal vie ws, fat–glandular inter-

What do you think?
faces, the fatty stripe of tissue between the pectoral muscle and the
glandular tissue on the mediolateral oblique (MLO) views, the upper
In this patient, the potential abnor mality may not be readily appar-
cone of tissue on the MLO views and the subareolar areas. You need
ent. In these situations, it is par ticularly important to re view the
to focus carefully: Unlike most masses and calcifications, the per
films systematically, looking specifical y for a mass, calcifications
ception of distortion is difficult and requires special attention.
distortion, or asymmetr y. Evaluate specific locations includin
C D
Figure 2.34. (Continued) Craniocaudal (C) and mediolateral oblique (D) photographically coned views of the anterior aspect of the left breast.
Focus your attention anteriorly. Look for straight lines and an aspect of the distortion as well as along the straightened trabecula.
overall disruption of tissue architecture. In some patients you may As you focus your search of the subareolar area, do y ou see the
see what appear as small locules of f at clustered in the central distortion?
E
F
Figure 2.34. (Continued) Craniocaudal (E) and mediolateral oblique (F) photographically coned views of the anterior aspect of the left breast; area of dis-
tortion is delineated by box.
ing for it will help you enhance your perception skills for subtle dis-
How can you increase your perception skills for
tortion. Previous films and a histo y of prior breast biopsies or trauma
distortion? should be obtained. If the patient has not had a prior breast biopsy or
significant trauma to the left subareolar area and this finding repre
One way to enhance your perception of distor tion is to evaluate the
sents an interval change, additional evaluation is indicated.
mammograms of w omen who have had a prior sur gical biopsy.
Although in many of these women no abnormality is apparent, in a
small number, subtle distortion can be seen at the biopsy site; look-
G H
I J
Figure 2.34. (Continued) 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.

Do the compression views help? How would you
be considered.
describe the imaging findings? An invasive lobular carcinoma is reported on the core samples. A
2.2-cm, grade I invasive ductal carcinoma with prominent lobular
Distortion is confi med on the spot compression views. An irregu-
features is reported on the lumpectomy specimen. Three excised sen-
lar, vertically oriented, hypoechoic, 2-cm mass with indistinct,
tinel lymph nodes are normal [pT2, pN0(sn)(i), pMX; Stage IIA].
angular, and microlobulated mar gins and associated shadowing is
imaged at the 12 o’clock position, 2 cm from the left nipple.
PATIENT 32
Figure 2.35. Screening study, 55-

B year-old woman. Craniocaudal (A)
and mediolateral oblique (B) views.
uation is indicated. If this finding is sta le, decreasing in size, or has

Any observations?
previously been evaluated, additional evaluation may not be indicated.
A mass is present in the right subareolar area. If prior studies are vail-
a
able, comparison will be helpful. If this finding is nw, additional eval-
D
Figure 2.35. (Continued) Craniocaudal (C) and mediolateral oblique (D) views, 16 months prior to (A) and (B).
What do you think, and what BI-RADS® assessment

category would you assign?
The finding in the right breast represents a change.Additional evalu-

ation with spot compression views and ultrasound is recommended.
Figure 2.35. (Continued) Craniocaudal (E) and mediolateral oblique (F) spot compression views,
right breast.
G H
Figure 2.35. (Continued) Ultrasound images in radial (RAD) (G) and antiradial (ARAD) (H) projections, right subareolar area, cor responding to the
site of mammographic concern.
not otherwise specifie , mucinous, medullary, or papillary carcino-

How would you describe the imaging findings, and how
mas are additional considerations. The bottom line? A solid mass
would you sort through the differential? developing in a postmenopausal woman requires biopsy.
A mass with indistinct and obscured margins is imaged on the spot
be considered.
compression views. A hypoechoic mass, with angular mar gins and
An ultrasound-guided biopsy is done at the completion of the
associated prominent ducts extending toward the nipple and branch-
diagnostic evaluation.
ing away from the nipple (Fig. 2.35I, J) is imaged at the 10 o’clock
Invasive ductal and intraductal carcinomas are repor ted on the
position, 1 cm from the right nipple. A fibroadenoma is unli ely to
ultrasound-guided core biopsy. A 1.5-cm g rade I invasive ductal
develop in a 55-y ear-old woman, particularly if she is not on hor-
carcinoma and associated solid and cribriform ductal carcinoma in
mones, and the imaging features are not typical of a fibroadenoma
situ without necrosis are repor ted on the lumpectom y specimen.
Although the patient has no history of nipple discharge, and none is
Micrometastatic disease detected on the hematoxylin-eosin (H&E)
elicited during the ultrasound study, a papillary lesion is a significan
slides (0.2 mm but 2 mm in size) is repor ted in two of three
consideration given the subareolar location and the associated duc-
excised sentinel lymph nodes (pT1c, pN1mi, pMX; Stage IIB).
tal changes noted on the ultrasound study. Focal fibrosis, pseudoan
giomatous stromal hyperplasia (PASH), invasive ductal carcinoma
I J
Figure 2.35. (Continued) 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”).
the excised lymph node. Some of the effects of this more thorough
What changes in the handling of lymph node
pathologic evaluation include the obser vation of isolated tumor
specimens have been seen with the introduction of cells and micromestatic disease. Consequentl y, the significance o
sentinel lymph nodes biopsies? these findings (isolated tumor cells and micrometastasis) i volving
excised sentinel lymph nodes is not y et clear, and there is no con-
The advent and now widespread use of sentinel lymph node biopsy sensus on their pro gnostic significance. Cu rently, the use of IHC
has resulted in a more meticulous e valuation of the excised lymph evaluation of sentinel lymph nodes is not encouraged; however, it is
node(s). This includes serial sectioning of the entire lymph node (as done at many institutions. The determination of micromestatic dis-
opposed to sample sections from multiple lymph nodes) and a more ease should be based on routine H&E histologic evaluation.
focused histologic and immunohistochemical (IHC) e valuation of
PATIENT 33
B
tioned so that they are parallel to the edge of the pectoral muscle.
What do you think?
For me, this lesion is three finger breadths posterior to the nippl
Is this a normal mammogram, or do you think (“X” cm, Fig. 2.36C). On the CC vie w, if I place my three finger
additional evaluation is indicated? parallel to the edge of the film (“X” cm, ig. 2.36D), the potential
lesion will probably be somewhere along the course of m y finger
Review the images carefully, using a systematic approach. Di vide (i.e., on a line drawn perpendicular to the arrow, Fig. 2.36D). This
the images in thirds so that you focus your attention on smaller por- is obviously a rough measure, but it is helpful in deter mining if
tions of the mammograms and look specifical y for masses, calcifi observations you make on one view have a corresponding potential
cations, asymmetric areas, distor tion, and diffuse changes section finding on the other projection. In this patient, there is a potential
by section. Do y ou notice anything? How about an area of asym- abnormality noted on the CC vie w (box). This may be superim-
metry on the left, when you evaluate the upper third of the medio- posed glandular tissue; however, with what degree of certainty can
lateral oblique (MLO) vie ws? Is there a comparab le potential we establish this on the screening vie ws? Do we mention it on the
abnormality on the left craniocaudal (CC) vie w? How can y ou report, hedge and let it go, or do w e call the patient back for addi-
determine this? Although you can measure with a r uler, an easier tional views?
way is to determine how many finger breadths behind the nipple th BI-RADS category 0: need additional imaging evaluation.
lesion is located on the MLO , making sure y our fingers are posi
D
Figure 2.36. (Continued) Mediolateral oblique (C) and craniocaudal (D) views. The potential abnormal-
ity noted in the mediolateral oblique view is measured to be “X” cm posterior to the nipple. If there is a cor-
responding abnormality on the craniocaudal vie w, one can e xpect to find it along a line dr wn to “X” cm
from the nipple. A potential corresponding area of asymmetry is found in the craniocaudal view, within the
box.
F Figure 2.36. (Continued) Craniocaudal (E) and mediolat-

eral oblique (F) spot compression views, left breast.
the absence of a history of a surgical biopsy or significant traum

at this site, cor relative physical examination and ultrasound are
Are you surprised? undertaken.
The spot compression views demonstrate a 1-cm area of distortion
corresponding to the area of concer n on the screening study . In
G H
Figure 2.36. Ultrasound images, radial (RAD) (G) and antiradial (ARAD) (H) projections corresponding to the area of mammographic concern.
How would you describe the ultrasound findings, and What do you think about the size described
what is your recommendation? pathologically?
Does this correlate with the imaging findings?
A vertically oriented, irregular, hypoechoic mass with indistinct Why not?
margins and shado wing is consistentl y imaged at the 1 o’clock
position, 4 cm from the left nipple. This corresponds to the area of This is one of the reasons I call in vasive lobular carcinoma the
mammographic concern. There is no cor responding palpable “sleaze disease.” Small monomorphic cells that invade tissue in sin-
abnormality detected as this area is scanned. gle files without fo ming nests of cells or disr upting surrounding
BI-RADS® category 4: suspicious abnor mality; biopsy should structures characterize in vasive lobular carcinoma histolo gically.
be considered. Consequently, invasive lobular carcinomas can be clinically, mam-
An invasive lobular carcinoma is diagnosed follo wing ultra- mographically, and pathologically (the invading cells can resemble
sound-guided core biopsies. A 4.2-cm invasive lobular carcinoma is lymphocytes) subtle. When we see something mammographically,
reported on the lumpectomy specimen; associated atypical lobular the findings common y underestimate the e xtent of disease found
hyperplasia is present. No metastatic disease is diagnosed in tw o histologically (i.e., what we see mammographically is often the tip
excised sentinel lymph nodes [pT2, pN0(sn)(i), pMX; Stage IIA]. of the iceberg).
PATIENT 34
B
affected breast, localized skin thick ening and retraction, architec-

What are the pertinent observations, and what is your
tural distortion, a spiculated or mix ed-density (fat containing)
working hypothesis? mass, oil c ysts, dystrophic calcifications, and areas of focal o
global parenchymal asymmetry in the contralateral breast.
Global parenchymal asymmetry is present in the right breast. The
BI-RADS® category 1: negative. In general, for benign findings
left breast is smaller and there is subtle distor tion on the left, such
if the observations represent a change from the prior mammogram,
that the prior breast sur gical history should be re viewed. In this
I describe them in the repor t and use BI-RADS® cate gory 2:
patient, the findings are iatr genic. The patient has had a biopsy in
benign finding. If the findings are st le compared with prior mam-
the left breast, so the tissue on the right is no w asymmetric.
mograms, I do not describe them and use category 1 for the assess-
Following excisional biopsies, no mammo graphic abnormality is
ment. Annual screening mammography is recommended.
apparent in 50% of the patients. Changes that can be seen fol-
lowing an e xcisional biopsy include a decrease in size of the
PATIENT 35

remember—make no assumptions! Is this mass w ell circum-

Is this a normal mammogram, or is it potentially
scribed? Can y ou unequivocally identify a f atty hilum? Can y ou
abnormal? How many lesions do you think may be establish the stability of this finding?Without prior films, hich are
present, and with what degree of certainty can you not available, the stability of this finding cannot be dete mined. On
determine the significance of any finding? the current study, it is not possible to confident y describe the mar-
gins as well circumscribed, nor can the presence of a fatty hilum be
A mass is present in the upper outer quadrant of the right breast (or, established; consequently, additional evaluation is indicated.
given the craniocaudal vie w, are there two?). Although you might BI-RADS® category 0: need additional imaging evaluation.
be tempted to think that this is an intramammar y lymph node,
Figure 2.38. (Continued ) Craniocaudal (C) and

D mediolateral oblique (D) spot compression vie ws,
right breast.
E F
Figure 2.38. (Continued) Ultrasound image, radial (RAD) (E) projection and ultrasound image, radial projection (F).
An invasive mammary carcinoma is reported on the core biopsy

samples. A 1.2-cm g rade III in vasive mammary carcinoma,
recommendation? micropapillary type, is repor ted on the lumpectomy specimen. No
metastatic disease is diagnosed in one excised sentinel lymph node
The spot compression vie ws confi m the presence of tw o masses
[pT1c, pN0(sn)(i), pMX; Stage I].
with indistinct margins. On ultrasound, the larger of the two masses
Invasive micropapillary carcinoma is a recently described entity.
(Fig. 2.38E) is irregular in shape, vertically oriented, and character-
Unlike this patient, most of the patients described in the literature
ized by angular mar gins. The smaller of the tw o masses (within
with this type of tumor have associated involvement of the axillary
box, Fig. 2.38F) is round with small spiculations. Both masses are
lymph nodes. As a result, this type of carcinoma has been associ-
at the 10 o’clock position, zone 2 in the right breast.
ated with a poor prognosis.
be considered.
PATIENT 36
Now, go to the mediolateral oblique (MLO) view and, angling your

What is the main observation?
fingers (Fig. 2.39F) so that they are parallel to the ob liquity of the
pectoral muscle, look for a cor responding abnormality at the edge
Divide the images in thirds (F ig. 2.39C, D) so that y ou focus your
of your finger—do ou see it? Before calling the patient back, prior
attention on smaller portions of the mammograms and look specif-
films (not shown) are reviewed and indicate that this is an inter val
ically for masses, calcifications, asymmetric areas, disto tion, and
change.
diffuse changes in a systematic pro gression. 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 appr ximate the distance from the nipple back
to the asymmetric area on the craniocaudal (CC) view (Fig. 2.39E).
Figure 2.39. (Continued ) Craniocaudal (C) and mediolat-

eral 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
D between the right and left breasts looking for masses, areas of
parenchymal asymmetry, distortion, and calcifications.
Figure 2.39. Craniocaudal (E) and mediolateral oblique (F) views. With the identification of an area o
parenchymal asymmetry, medially in the left craniocaudal view, you can use your fingers to estimate the dis
tance of this area from the nipple. No w, go to the mediolateral oblique view and, angling your fingers so tha
they are parallel to the ob liquity of the pectoral muscle, y ou can identify a cor responding abnormality at the
edge of your finger inferior y on the mediolateral oblique view.
Figure 2.39. (Continued) Craniocaudal (G) and mediolateral oblique (H), spot compression views.
I J
Figure 2.39. (Continued) Ultrasound images in radial (I) and antiradial (J) projections at the 7 o’clock position, 4 cm from the left nipple.

be considered.
what is your recommendation?
An invasive mammary carcinoma with focal mucinous features
is reported on the core biopsies. A 1.2-cm, grade II invasive ductal
The spot compression views confi m the presence of a 1.5-cm mass
with mucinous features is repor ted on the lumpectom y specimen.
with indistinct margins. On ultrasound, the mass is nearly isoechoic;
Associated solid and cribrifor m ductal carcinoma in situ with no
however, it is detected and characterized b y an irregular shape and
necrosis is also reported. The sentinel lymph node is normal [pT1c,
angular margins.
pN0(sn)(i), pMX; Stage I].
PATIENT 37
4. Splitting the images in thirds, look for specific lesions: (a) masses
Is this mammogram normal?
(b) calcifications; (c) disto tion; and (d) islands of asymmetry.
Review the images systematically:
1. Technically, is this an adequate study? Positioning is not opti- Is this a normal study? What is indicated next
mal, particularly on the mediolateral oblique (MLO) views; (be specific)?
however, the images are adequate.
2. Are there diffuse changes? BI-RADS® category 0: need additional imaging e valuation.
3. Evaluate specific locations: (a) medial quadrants on the cranio Magnification views in tw o projections are indicated for fur ther
caudal views; (b) fat–glandular interfaces; (c) fatty stripe of evaluation.
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.
Figure 2.40. (Continued) Craniocaudal (C) and mediolateral oblique (D) double spot compression
magnification vi ws, right breast.
A cluster of pleomorphic calcifications is conf med on the dou- Appropriate action is tak en in the for m of a stereotacticall y
ble spot compression magnification vi ws. There are linear calcifi guided biopsy. A high-nuclear-grade ductal carcinoma in situ with
cations characterized by irregular margins and clefts. Additionally, associated central necrosis is reported. This diagnosis is confi med
linear and round calcifications demonstrate linear orientation. This on the lumpectomy specimen [pTis(DCIS), pNX, pMX; Stage 0].
represents at least ductal carcinoma in situ until proven otherwise. No invasive disease is diagnosed. No sentinel lymph node biopsy is
BI-RADS® category 5: Highl y suggestive of malignanc y; done.
appropriate action should be taken.
PATIENT 38

to the area of parench ymal asymmetry. If there is an y question

How would you describe the findings on this
about a cor responding palpable abnormality, the patient can be
mammogram? asked to return for correlative physical examination and, if needed,
additional mammographic images, ultrasound , or, occasionally,
Global parenchymal asymmetry can be described in the right breast.
magnetic resonance imaging.
Establishing the presence of global parenchymal asymmetry requires
comparison with the contralateral side. A greater volume of tissue is
if the observations represent a change from the prior mammogram,
present in the right breast compared to the same area in the left breast.
I describe them in the repor t and use BI-RADS® cate gory 2:
As defined in the ourth Edition of BI-RADS®, global asymmetr y
benign finding. If the findings are st le compared with prior mam-
should involve at least a quadrant of the breast. Although breast tissue
mograms, I do not describe them and use category 1 for the assess-
is more commonly symmetric, global asymmetry, as demonstrated
ment. Annual screening mammo graphy is recommended for this
here, can be seen in a small number of woman as a normal variant. No
patient.
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 parench ymal asymmetry, it is criti-

cal to establish that there is no palpable abnormality corresponding
PATIENT 39
on MLO views, the superior cone of tissue on MLO views, medial

What observations can you make, and what would you
tissue on CC views, and subareolar areas. Focus down with a mag-
like to do next?
nification lens, particularly when looking for small masses, distor-
tion, and clusters of calcifications. Is there a potential mass wit
A mass is present in the left breast, best seen on the craniocaudal
distortion in this patient? Where? On the CC vie ws, review the
(CC) view, directly posterior to the nipple. Are there an y other
fat–glandular interfaces particularly abutting the retro glandular
observations? Review the images systematically. Focus your atten-
area on the right (F ig. 2.42C). On the MLOs, look at the upper
tion on smaller amounts of tissue by splitting the CC and mediolat-
thirds of the MLOs and more specifical y at the upper cone of tis-
eral oblique (MLO) views into thirds. Look for specific finding
sue on the right MLO (F ig. 2.42D). Do you see the mass? Do y ou
including diffuse changes, masses, distortion, asymmetry, and cal-
see the distortion? Additional evaluation is indicated bilaterally.
cifications. Review areas on the mammo grams where breast can-
cers are likely to develop, specifical y, fat–glandular interfaces, the
fatty stripe of tissue between pectoral muscle and glandular tissue
Figure 2.42. (Continued) Craniocaudal (C) views with a box on possible mass with distor tion. Mediolateral
oblique views (D), with box delineating asymmetry involving the upper cone of tissue on the right breast.
E F
Figure 2.42. (Continued) Craniocaudal (E) and mediolateral oblique (F) spot compression views, right breast.
G H
Figure 2.42. (Continued) Ultrasound images, radial (RAD) (G) and antiradial (ARAD) (H) projections, corresponding to the site of the mass seen mam-
mographically in the right breast.
BI-RADS® category 5: Highly suggestive of malignancy; appro-

priate action should be taken.
recommendation? Appropriate action is taken in the form of an ultrasound-guided
core biopsy. Histologically, an in vasive mammary carcinoma is
The 1.2-cm mass in the left breast is a c yst (images not sho wn)
reported on the cores. A grade II, invasive ductal carcinoma meas-
and requires no further intervention. The spot compression views
uring 2.7 cm is repor ted on the lumpectomy specimen. Associated
on the right confi m the presence of an irregular 2.5-cm mass with
intermediate-grade, solid-type ductal carcinoma in situ is also pres-
associated distortion and lo w-density amorphous calcification
ent. Two excised sentinel lymph nodes are ne gative for metastatic
(Fig. 2.42E, F). On ultrasound, an irregular, hypoechoic mass with
carcinoma [pT2, pN0(sn)(i), pMX; Stage IIA].
areas of shadowing is imaged at the 12:30 o’clock position, 12 cm
from the right nipple (Fig. 2.42G, H).
PATIENT 40
views. A metallic BB on the left marks a skin lesion.
glandular tissue on MLO vie ws, the superior cone of tissue on

What do you think?
MLO views, medial tissue on CC vie ws, and subareolar areas.
What, if anything, would you like to do next? Focus down with a magnification lens, pa ticularly when looking
for small masses, distortion, and clusters of calcifications. Do ou
Review the films systematical y. There are scattered dystrophic cal-
notice anything when you evaluate medial tissue on the CC vie ws
cifications and ar terial calcifications bilateral y. Focus your atten-
(Fig. 2.43C)? How about at the edge of the film on the left? Becaus
tion on smaller amounts of tissue by splitting the craniocaudal (CC)
there is nothing readil y apparent on the MLO vie w, are you com-
and mediolateral oblique (MLO) views into thirds. Look for spe-
fortable describing this as a nor mal mammogram? With what
cific findings, including di fuse changes, masses, distortion, asym-
degree of certainty can you dictate a report on this screening study?
metry, and calcifications. R view areas on the mammograms where
Could a lesion have been excluded on the MLO view?
breast cancers are lik ely to de velop, specifical y, fat–glandular
interfaces, the f atty stripe of tissue betw een pectoral muscle and
Figure 2.43. (Continued) Craniocaudal (C) views. Limiting evaluation to the medial quadrants of the
breasts focuses your evaluation on smaller amounts of tissue. Now look specifical y for a possible mass.
Do you see it?

D
Figure 2.43. (Continued) Craniocaudal (D) spot compression view, left breast.
E F
Figure 2.43. (Continued) Ultrasound images, in radial (RAD) (E) and antiradial (ARAD) (F) projections at the 7 o’clock position, 9 cm from the left nip-
ple.
How would you describe the findings? With respect to imaging this lesion on the orthogonal
view, what view might be helpful and why? Be specific.
The spot compression view confi ms the presence of a spiculated
mass posteromedially in the left breast. Based on this information, When considering 90-degree lateral views, there are two possibili-
what is your degree of certainty that there is a significant abnor ties: a 90-de gree lateromedial (LM) or a 90-de gree mediolateral
mality and that a biopsy is indicated? Is it no w possible to dictate (ML) view. For the 90-de gree LM vie w, the buck y is placed up
a succinct, def initive, and directi ve report? On ultrasound , a against the sternum so that a maximal amount of medial tissue is
hypoechoic spiculated mass, with intense shado wing and vertical included on the image and , because medial tissue is closest to the
orientation, is identified at the 7 o’clock position, 9 cm from th film, resolution of medial lesions is impro ved. For the 90-degree
left nipple. ML view, the bucky is placed laterally and compression is applied
Time and time again, y ou will find that y following a simple, medially. In this patient, a 90-de gree LM view provides the best
logical process, and completing the image workup, you will deliver chance to image the lesion on the orthogonal view.
optimal patient care that minimizes the lik elihood of delaying the BI-RADS® category 4: suspicious abnor mality; biopsy should
diagnosis of breast cancer. be considered.
This patient illustrates the need to focus keenly on tissue extend- Rather than just consider biopsy, one is undertaken using ultrasound
ing to the edge of the films. The fact that this lesion is not imaged guidance. An invasive ductal carcinoma is diagnosed on the core sam-
on the MLO view should not dissuade you from calling the patient ples. A 1.2-cm, g rade I invasive ductal carcinoma is repor ted on the
back. With far posteromedial lesions, it is common to par tially lumpectomy specimen. No metastatic disease is repor ted in three
(barely) image them on only one of the two routine views. Usage of excised sentinel lymph nodes [pT1c, pN0(sn)(i), pMX; Stage I].
the spot compression paddle often allo ws more tissue to be
included on the image.
PATIENT 41
Figure 2.44. Screening study, 57-year-old woman. Craniocaudal (A) and mediolateral
oblique (B) views.
both CC views and, with it, possibly a lesion. The CC views need to
What are your observations?
be repeated.
An asymmetry with irregular margins is imaged in the right medi-
olateral (MLO) view anterior to the pectoral muscle; however, there
Do you have any other observations? What else would
is no cor responding abnormality on the craniocaudal (CC) vie w.
you like at this point?
Are there any other observations? Is breast positioning optimal on
the CC views? How can you tell? Do y ou see pectoral muscle in
How about prior studies? Ideall y, when you observe a potential
either CC view? Do you see cleavage in either CC view? When you
abnormality on a screening study, you should review prior films an
cannot see pectoral muscle or cleavage on CC views, you must con-
determine if the patient has had any surgery or trauma localized to
sider the possibility that posterior tissue has been excluded from
the site of concer n. Although it would be appropriate to call this
the image. Under these circumstances, you should measure the pos-
patient back for fur ther evaluation if there are no prior studies or
terior nipple line (PNL). The PNL measurement on the CC vie w
they are unavailable, you do not want to recall patients in whom the
should be within 1 cm of that measured on the MLO vie w (Fig.
potential abnormality has decreased in size, been previously evalu-
2.4E, F). If the measurements are not within a centimeter of each
ated, or if it reflects postoperat ve changes.
other, posterior tissue has been excluded and the CC image needs to
be repeated. In this patient, posterior tissue has been excluded from
Figure 2.44. (Continued) Craniocaudal (C) and mediolateral

D oblique (D) views, screening study 2 y ears prior to (A) and (B).
No history of breast surgery or trauma.
on the prior CC vie w. In comparing the tw o studies, do y ou have

What do you think? Does the patient need additional
any other observations? What is the next step?
evaluation?
The patient is called back for fur ther evaluation. Did you notice
The area of asymmetry has increased in size compared to the prior
the new nodule in the left breast (Fig. 2.44E, F, arrows)? What will
study and, with better positioning on the CC vie ws, it can be seen
you ask the technologist to do on the right? How about on the left?
Figure 2.44. (Continued ) Craniocaudal (E) and

mediolateral oblique (F) views. There is a mass in the
F left breast (arrows). This represents a change from
the prior study and therefore also requires evaluation.
G
Figure 2.44. (Continued) Repeat craniocaudal (G) views. With better positioning, the lesion is now
seen in this projection laterally.
the mammographic technologist to identify the inframammary fold

What can be done to maximize visualization of lateral
(IMF) and lift the breast as much as the natural mobility of the IMF
tissue on craniocaudal views? permits. Additionally, the technologist needs to pull the tissue out
away from the body and routinel y tug on the lateral aspect of the
The lesion in the right breast was excluded from the field of vi w on
breast to maximize the amount of posterolateral tissue included on
the initial craniocaudal (CC) view. Repeat CC views, with a tug on
the images. If, after the lateral tug is done, tissue is still seen
the lateral aspect of the breast, will maximize the amount of lateral
extending to the edge of the film lateral y, and there is tissue poste-
tissue included on the images. Alternatively, an exaggerated cranio-
riorly superimposed on the pectoral muscle on the MLO vie w, an
caudal view, laterally (XCCL), can be done. The XCCL view can
XCCL view may be indicated.
be done using the large compression paddle or a spot compression
paddle. When positioning patients for CC views, it is important for
Figure 2.44. (Continued) Mediolateral oblique (H) spot compression view, right breast. Craniocaudal (I) and
mediolateral oblique (J) spot compression views, left breast.
K L
Figure 2.44. (Continued) 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.
How would you describe the findings? How are multifocality and multicentricity defined? How
about synchronous and metachronous lesions? What is
Spot compression views, bilaterally, confi m the presence of bilat- emerging as the modality of choice in evaluating
eral lesions. The mass on the right is irregular with spiculated mar- patients diagnosed with breast cancer?
gins and some associated calcifications and measures appr xi-
mately 2 cm. A hypoechoic mass with intense shado wing, an If you identify one suspicious (and obvious) finding, be sure to con
echogenic halo, vertical orientation, and spiculation is identified o tinue looking at the mammo gram for other lesions bilaterall y.
ultrasound at the 10 o’clock position, 8 to 10 cm from the right Multifocal lesions occur in the same quadrant and multicentric
nipple. The mass on the left is round with indistinct and possib ly lesions are found in different quadrants in the same breast. Bilateral
microlobulated margins and measures appro ximately 0.7 cm. An breast cancers are synchronous if the y are diagnosed at the same
irregular, hypoechoic mass, with angular margins and an echogenic time and metachronous if the y are diagnosed after an arbitrar y
halo, is found in the left breast at the 4 o’clock position, 5 cm from interval (e.g., 6 or 12 months from the initial cancer diagnosis).The
the nipple. This corresponds to the expected location of the lesion published literature relative to the incidence of multifocality and
seen mammographically in the left breast. Biopsies are indicated multicentricity is limited and dif ficult to review because there are
bilaterally. Be mindful of any developing solid mass in post- significant differences in how the terms are defined and h w tissue
menopausal women, particularly if they are not on hormone is evaluated histologically. There are now good data supporting the
replacement therapy. use of magnetic resonance imaging (MRI) in evaluating patients for
BI-RADS® category 4: suspicious finding; biopsy should b multifocal, multicentric, and synchronous contralateral lesions, all
considered. of which could change the surgical management of the patient. We
Imaging-guided biopsies are done bilaterally. Invasive and intra- recommend bilateral breast MRI in all of our patients with a ne w
ductal carcinomas are reported bilaterally on the ultrasound-guided diagnosis of breast cancer.
core samples.
PATIENT 42
B Figure 2.45. Screening study, 40-year-old woman. Craniocaudal

(A) and mediolateral oblique (B) views.
clinical manifestations of Poland’s syndrome are variable. It is postu-

What observations can you make, and what underlying
lated that h ypoplasia or damage to the subcla vian artery, or its
condition do you think the patient has? branches, in utero leads to the range of developmental abnormalities
reported in these patients. Mammographic manifestations in this syn-
The left breast is smaller than the right, and there is no pectoral
drome include hypoplasia of the ipsilateral breast, inability to visual-
muscle imaged on the left. In some patients, the pectoral muscle
ize the pectoralis muscle, and absence of a nipple. Association with
may not be imaged secondar y to a histor y of prior trauma (e.g., a
malignancies including leukemia, lymphoma, and leiomyosarcoma
burn) to the chest wall or shoulder, or a stroke, such that the patient
has been reported in these patients. There have also been several case
is unable to cooperate with positioning. Alternatively, Poland’s syn-
reports of breast cancer identified in omen with Poland syndrome.
drome should be considered. This patient has no history of trauma
or stroke. She has Poland’s syndrome.
if the observations represent a change from the prior mammogram, I
Poland’s syndrome is a rare, sporadic congenital malformation with
describe them in the repor t and use BI-RADS® cate gory 2: benign
unilateral hypoplasia of the chest wall, ipsilateral hand abnormalities,
finding. If the findings are sta le compared with prior mammograms,
absence of the costoster nal portion of the pectoralis major muscle,
I do not describe them and use category 1 for the assessment. Annual
absence of the pectoralis minor muscle, and absence of the second ,
screening mammography is recommended in this patient.
third, and fourth or third, fourth, and fifth costal ca tilages or ribs. The
PATIENT 43
sider evaluating the study for technical adequac y and the presence
Is this a normal mammogram?
of diffuse changes. When they are bilateral, diffuse changes can be
hard to perceive. Did you notice the prominence of the trabecular
A pacemaker is present in the left subpectoral region and there are
markings? This becomes par ticularly striking when you compare
scattered dystrophic and v ascular calcifications. Before focusin
with a study from 2 years previously.
your attention on the search for subtle signs of breast cancer , con-
Figure 2.46. (Continued ) Comparison screening study, 2 y ears previously. Craniocaudal (C) and
mediolateral oblique (D) views.
hormone replacement therapy (e.g., estrogen), weight change, con-

What is your differential?
gestive heart failure, renal failure with fluid verload, and superior
vena cava syndrome. Additional rare benign causes include granu-
Differential considerations for diffuse changes that are usually uni-
lomatous mastitis, coumadin necrosis, ar teritis, and autoimmune
lateral, although rarely can be bilateral, include radiation therap y
disorders (e.g., scleroderma). Obtaining a thorough histor y, exam-
effect, inf ammatory changes (e.g., mastitis), trauma, ipsilateral
ining the patient, and an ultrasound are often helpful in sor ting
axillary adenopathy with lymphatic obstruction, dialysis shunt in
through the differential considerations.
the ipsilateral arm with fluid overload, invasive ductal carcinoma
In this patient, the findings reflect conges ve heart failure with
fluid overload. Signs and symptoms impro ve significant y with
diuretics; this applies to the mammographic changes as well.
increases in breast density and size or a decrease in breast size (the
shrinking breast). Dif ferential considerations for diffuse changes
that are usually bilateral, although the y can be unilateral, include
PATIENT 44
What is the diagnosis?
A serpiginous tubular structure is imaged in the upper outer quad-

rant of the left breast associated with scattered coarse calcifications
This is most lik ely a thrombosed v ein (varix) reflecting heale
Mondor’s disease. In most patients, Mondor’s disease resolves com-
pletely, with no residual imaging finding. Rare y, calcification m y
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 eins in the breast. The thoracoepi-
gastric and lateral thoracic v eins are the most commonl y involved.
In most patients, the cause is idiopathic. Ho wever, reported causes
of Mondor’s disease include breast trauma, breast surgery, imaging-
guided biopsies, sentinel lymph node biopsy, dehydration, excessive
physical activity, an inflammato y 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 ipsi-
lateral arm is raised, or superficial se piginous nodularity (simulat-
ing the appearance of a v aricose vein) corresponding to the course
of the involved vein. Mammographically, the affected vein may have
a rope- or beadlike appearance. On ultrasound, a superficial beade
tubular structure may be imaged, corresponding to the linear dim-
pling. Mondor’s disease typically resolves spontaneously. Patients
C are reassured of the lik ely benign nature of this condition and sup-
ported with nonsteroidal, anti-inflammato y agents for symptomatic
Figure 2.47. (Continued) Mediolateral oblique, photographically coned
view (C), left breast. relief of associated tenderness.
is recommended in 1 year.
PATIENT 45
A B
tant, masses are present bilaterall y. Comparison with prior studies

What observations can you make, and what would you
is important to determine if these represent an inter val change, in
like to do next? which case additional evaluation is indicated. If the masses are sta-
ble or decreasing in size, or if they have been previously evaluated,
Lymph nodes and the pectoralis minor muscles (triangular densities
no further evaluation may be needed.
at the edge of the mediolateral ob lique views) are imaged bilater-
ally, superimposed on the pectoralis major muscles. More impor-
C D
Figure 2.48. (Continued) Craniocaudal (C) and mediolateral oblique (D) views, 2 years previously.
some suggest that no evaluation is indicated, provided the masses

Based on the prior studies, what would you
are similar in appearance mammo graphically. My approach to
recommend next?
women with multiple masses is to evaluate them at the first pres
entation with spot compression vie ws and ultrasound. If the
When compared with sequential prior studies (only one prior study
masses are c ysts, annual screening mammo graphy is recom-
is shown), multiple masses are seen bilaterall y with notab le size
mended. Thereafter, only new masses are e valuated with spot
fluctuations. These have been evaluated with ultrasound previously
compression views and ultrasound. If one or more lik ely benign
and therefore no further evaluation is indicated at this time, partic-
solid masses are imaged on ultrasound, a follow-up ultrasound is
ularly because the y have almost completel y regressed. Cysts are
recommended in 6 months. A biopsy is done when a mass is solid
common and can occur at any age, including during adolescence. In
and does not fit the criteria for a proba ly benign lesion following
many women, however, cysts develop, or become more prominent,
a complete workup.
during the perimenopausal period. If no hor mone replacement is
BI-RADS® category 1: ne gative. Next screening mammo-
used, most c ysts regress spontaneously following menopause. A
gram is recommended in 1 year. (If for some reason the masses
second, smaller peak of cyst development is seen in women in their
are described in the repor t, a BI-RADS® cate gory 2: benign
mid to late 70s and early 80s.
findings assessment is used and annual mammo graphy is
recommended).
How should women with multiple similar masses on a
screening mammogram be managed?
The management of w omen with multiple masses on screening

mammograms is controversial. Given a low yield of malignancy,
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Cha pter 3
Diagnostic Breast Imaging
■ TERMS
Adenosis tumor Hematoma Posttraumatic change
Air gap Invasive ductal carcinoma not otherwise Pneumocystography
Axillary lymph node dissection (ALND) specified (NOS) Probably benign lesion
Cat scratch disease Invasive lobular carcinoma Psammoma bodies
Columnar alteration with prominent Lactational adenoma Pseudoangiomatous stromal
apical snouts and secretions (CAPSS) Lipoma hyperplasia (PASH)
Complex fibroadenoma Lobular neoplasia Radial scar
Complex sclerosing lesion (CSL) Lymphovascular space involvement Sclerosing adenosis
Cyst Male breast cancer Sebaceous cyst
Diabetic fibrous mastopathy Mastitis Secretory calcification
Double spot compression magnification Medullary carcinoma Sentinel lymph node biopsy (SLNB)
views Metachronous carcinoma Shrinking breast
Ductal carcinoma in situ (DCIS) Metaplastic carcinoma Spot compression views
Epidermal inclusion cyst Metastatic disease Spot tangential views
Extensive intraductal component (EIC) Milk of calcium Subareolar abscess
Extra-abdominal desmoid Mucinous carcinoma Synchronous carcinoma
Extracapsular tumor extension Multiple peripheral papillomas Touch imprints
Fat necrosis Neoadjuvant therapy Triangulation of lesion location
Fibroadenoma Oil cyst Tubular adenoma
Fibromatosis Papillary carcinoma Tubular carcinoma
Focal fibrosis Papilloma Tubulolobular carcinoma
Focal spot Perineural invasion Tumor necrosis
Galactocele Peripheral abscess Vascular calcification
Granular cell tumor Phyllodes tumor
Gynecomastia Port-a-catheters
■ INTRODUCTION during neoadjuvant chemotherapy for breast cancer. At some facil-

ities, and according to the American College of Radiology (ACR)
The diagnostic patient population is made up of women called back Practice Guideline for the Performance of Diagnostic Mammography,
for potential abnor malities detected on a screening mammo gram, women with implants may also be included in the diagnostic patient
patients who present with signs and symptoms of disease localized population.
to the breast(s), patients with a history of breast cancer treated with This chapter describes one approach to the diagnostic evaluation
lumpectomy and radiation therapy, and those undergoing follow-up of patients with breast related findings, hich I have developed and
228 Chapter 3 • Diagnostic Breast Imaging
fine-tuned through y ears of e xperience and thousands of patient bilaterally, as well as a spot tangential view of the focal abnormality.
encounters. I provide the rationale for a common-sense, streamlined A unilateral study (CC and MLO views) of the symptomatic breast
approach and illustrate principles that I think you will find practical with the spot tangential vie w at the site of focal concer n is done if
efficient, and helpful in minimizing a delay in a breast cancer diag- the patient has had a mammo gram within the preceding 6 months.
nosis. Simplicity, creativity, and resourcefulness in problem solving Based on what is seen on these initial images, additional spot com-
are all components of the approach. Ob viously, there are many dif- pression, or double spot compression magnification vi ws, may be
ferent ways of approaching this patient population, and again m y oftained. Depending on the location of the focal finding, and th
recommendation is that y ou select a method that w orks in y our appearance of this area on the spot tangential view, correlative phys-
hands, and use it consistently. Do not shor t-circuit evaluations for ical examination and an ultrasound are usually indicated. The ultra-
the sake of expediency, be fl xible and creative (but keep it simple) sound may be deferred in patients in w hom there is no chance that
in sorting through dilemmas, make no assumptions, and demand the the lesion has been excluded from the field of vi w and completely
highest quality possible from yourself and those around you. fatty tissue, or a benign lesion (e.g., an oil cyst or a dystrophic calci-
Although I pro vide the imaging algorithms I use, a dedicated fication), is imaged co responding to the area of concern.
breast imaging radiologist directs all diagnostic evaluations and can
tailor the e xam to the patient and the prob lem being e valuated.
Results, impressions, and recommendations are discussed with the ■ DIAGNOSTIC EVALUATION OF PATIENTS
patient directly at the time of the evaluation. Tools available to eval- UNDER AGE 30 YEARS, PREGNANT, OR
uate patients include mammo graphic images, cor relative physical
LACTATING, WITH FOCAL FINDINGS
examination, ultrasound, cyst aspiration, pneumocystography, duc-
tography, imaging-guided fine-needle aspiration, and imaging For women under the age of 30 years, or who are pregnant or lactat-
guided needle biopsy. If indicated, magnetic resonance imaging of ing, who present with a “lump” or other focal symptom, w e start by
the breast is scheduled at the time of the patient’s diagnostic evalu- doing a physical examination and an ultrasound. In most of these
ation, including all patients diagnosed with breast cancer following patients, this is all that is required for an appropriate disposition.
an imaging-guided procedure. Rarely, if a breast cancer is suspected based on the physical exam and
ultrasound findings, a biopsy m y be indicated in this patient popula-
tion. If cancer is suspected, a full bilateral mammogram is also done.
■ ADDITIONAL MAMMOGRAPHIC VIEWS
For patients called back after screening, additional mammo graphic ■ OUR GOAL AND APPROACH RELATIVE
images are almost always taken. Virtually all of the additional views
imaged during diagnostic e valuations involve the use of the spot
TO DIAGNOSTIC EVALUATIONS
compression paddle and include spot compression, rolled spot com- When patients present for diagnostic evaluations, our goal is to estab-
pression, spot tangential, and double spot compression magnificatio lish the correct diagnosis, accurately and efficient y, so we do as much
views. Spot compression and rolled compression vie ws are tak en as is indicated and the patient desires, in one visit. F or some women
when trying to deter mine if a lesion is present (or is it merel y an this may include mammographic images only, or additional views and
“imaginoma”), when establishing the mar ginal characteristics of a an ultrasound; for other patients, additional mammographic views, an
mass, or, with rolled views, for triangulating the location of a lesion ultrasound, and a core biopsy are perfor med. In my experience, if a
seen initially on only one of the routine views. Spot tangential views biopsy is indicated, the patient’s immediate question is “How soon can
are taken routinely in evaluating focal signs and symptoms. They are I have it done?” and they are appreciative (and in many ways relieved)
also used when a lesion is thought to be localized to the skin or to when I respond, “If you would like, we can do the biopsy no w and
position postoperative skin changes following lumpectomy and radi- have results by tomorrow.” Rarely, a patient requests time to discuss
ation, in tangent to the x-ray beam so that they are not superimposed the recommendation with her f amily; in that case, w e schedule the
and potentially obscuring significant changes at the lumpecto y bed. biopsy for a date that is convenient for the patient.
Double spot compression magnification vi ws are indicated w hen Histologic findings are discussed y the radiologist and the pathol-
evaluating calcifications. The only diagnostic images that are some- ogist who review the cores within 24 hours of the core biopsy , so
times done with the large compression paddle are lateral views (90- patients are asked to return the following business day to receive their
degree lateromedial or 90-degree mediolateral views) used to trian- results. The biopsy site is examined, biopsy results are discussed, and,
gulate the location of a lesion on the or thogonal view. As with based on the results, our recommendations re garding the need to
screening views, high-quality, well-exposed, high-contrast diagnostic return to screening guidelines, shor t-interval follow-up, excisional
images, with no blur or artifacts, are essential to minimize the likeli- biopsy, or surgical consultation are discussed with the patient. If a
hood of delaying or missing a breast cancer diagnosis. surgical consultation is indicated , this is scheduled for the patient
before she leaves our center. With a commitment from the breast sur-
geon, patients are seen within 48 hours of a breast cancer diagnosis.
■ DIAGNOSTIC EVALUATION OF PATIENTS OVER
THE AGE OF 30 YEARS WHO PRESENT WITH
FOCAL FINDINGS ■ BI-RADS® ASSESSMENT CATEGORIES USED
FOLLOWING DIAGNOSTIC EVALUATIONS
When women over the age of 30 y ears present with a “lump” or
other focal symptom (focal pain, skin change, nipple retraction, Under the Mammo graphy Quality Standards Act (MQSA), all
etc.), a metallic BB is placed at the site of focal concern. Then cran- reports involving mammographic images require an assessment
iocaudal (CC) and mediolateral ob lique (MLO) views are imaged category. Our approach, however, is to provide an assessment that
reflects our recommendation follo wing the completed diagnostic a position to re volutionize and substantially improve patient care.
evaluation. This usually incorporates the findings and impressio Carpe diem.
formulated following the physical examination, mammogram, and What, then, should our role be? Should our role be to inter pret
ultrasound (or other studies that ma y be done). So, in addition to films in isolation, or should it be that of clinicians and consultants
using BI-RADS® cate gories 1 and 2, and cate gory 3 (probab ly who interpret breast images? I consider my role to be that of a clin-
benign, short-interval follow-up), we also use cate gory 4 (suspi- ical consultant in breast imaging (rather than a radiolo gy report, I
cious abnormality, biopsy should be considered) and cate gory 5 dictate “breast imaging consultations”), and as such, the patients
(highly suggestive of malignanc y—appropriate action should be who come to see me are my patients. In the diagnostic setting,
taken), based on what is determined following the completed diag- rather than accept the histor y and physical examination described
nostic evaluation. Based on the likelihood of malignancy, category by others, I talk to the patients directly and, when indicated, under-
4 lesions can be subclassified into 4A (l w suspicion for malig- take a physical examination. As opposed to dele gating the breast
nancy), 4B (intermediate suspicion for malignancy), or 4C (moder- ultrasound study to a technologist, I view this as an opportunity to
ate concern, but not classic as in category 5). Category 0 is used for establish effective rapport with the patient, review the history pro-
patients for w hom we schedule magnetic resonance imaging for vided, and under take correlative physical examination (in ef fect,
further evaluation, and BI-RADS® category 6 (known malignancy) placing eyeballs at the tips of my fingers). Why not take this oppor-
is used primarily for patients with a breast cancer diagnosis who are tunity? We place a significant amount of impo tance on what our
receiving chemotherapy (e.g., neoadjuvant therapy) and are under- images show, but shun the infor mation provided by the ph ysical
going monitoring of chemotherapy response. Although in this text I examination and by talking directly with the patient. This informa-
use the ACR lexicon terminology, in our practice we have chosen to tion can be just as critical and impor tant in ar riving at the right
vary the verbiage provided with categories 4 and 5 to indicate that answer as any finding on our imaging studies.There are times when
a “biopsy is indicated” rather than “should be considered” or the imaging studies are negative or equivocal and a biopsy is indi-
“appropriate action should be taken” (more on this below). cated based on clinical findings
As I scan during the ultrasound study, I examine and talk with the
patient. In addition to the visual information from the ultrasound, I
find that use of the ultrasound coupling gel to e xamine a patient
■ SOME PHILOSOPHICAL CONSIDERATIONS enhances my ability to fin , feel, and characterize palpable findings
REGARDING PATIENT CARE AND DIAGNOSTIC During the real-time portion of the study, as I scan and examine the
EVALUATIONS: ARE WE FILM READERS OR patient, I determine if a lesion is present. After making this deter-
CONSULTANTS? mination, I take the images needed to adequately and appropriately
document the features of the lesion and that support the impression
Before going further, please indulge me in a shor t philosophical I formulate during the real-time por tion of the study (i.e., directed
discussion about ho w we, as radiolo gists, choose to practice image taking). I do not tak e pictures of nor mal tissue. Time and
breast imaging. Although some are lik ely to disag ree with sev- time again, I am impressed with how often the history obtained dur-
eral (and maybe all) of the concepts presented here, in generating ing these interchanges yields critical infor mation used to establish
a reaction, one way or the other, I accomplish my goal of getting the “true” nature and significance of hat is going on. The other
you to think about issues that are not usually thought about—but critical aspect of these interchanges is that it allows me to gauge the
perhaps should be. reaction of the patient to m y recommendations. I w ant patients to
As radiologists, we can effectively choose to dele gate many of understand and feel comfortable with what is happening. There are
our responsibilities as physicians to others, thereby minimizing our some who say we cannot afford to do this (i.e., it is not cost-ef fec-
direct role in the care of patients. We work hard during screening to tive). My response is to ask ho w can we afford not to do this? I
identify small breast cancers, y et we routinely relegate the role of would argue that it is more ef ficient and cost-effective, and I am
discussing our findings with patients to others. With this comes an convinced that this approach actually expedites high-quality patient
obfuscation of our critical role in the detection of clinicall y occult care.
early-stage breast cancer and possib le misrepresentations to For a moment, consider patients refer red to any specialist for a
patients relative to the limitations of mammography and the gener- consultation. If a gastroenterolo gist detects a pol yp during a
ation of unrealistic e xpectations regarding the appropriateness of colonoscopy, does he pull the scope out and dictate: “suspicious
ultrasound and magnetic resonance imaging. We struggle during abnormality, biopsy should be considered?” or “finding highy sug-
diagnostic evaluations to ar rive at an ans wer, yet we dismiss gestive of malignanc y—appropriate action should be tak en”?
patients with lines such as “You will get the results from your doc- Likewise, if a cardiologist detects a significant corona y lesion that
tor,” as though we are incapable (or unwilling) to do it, or we avoid can be managed ef fectively with an angioplasty, does she call the
all direct contact with the patient and have one of our surrogates tell referring physician for “permission” to proceed with an indicated
the patient that she should contact her physician for the results. We procedure? No, they go ahead and do what needs to be done to tak e
identify potential cancers, y et we won’t do the biopsy w hile the care of the patient. Why do we not consider a patient being sent to a
patient is in our f acility because it is not practical or e xpedient. breast imaging radiologist for evaluation in a similar light as a patient
Patients are ask ed to w ait for da ys and sometimes w eeks for a being sent to a breast surgeon for evaluation? Surgeons routinely do
biopsy to be done and then for results. If we do the biopsy, we often fine-needle aspirations and excisional biopsies on patients referred to
relegate patient follow-up and the discussion of results to the refer- them for clinical findings, ven when fatty tissue is imaged mammo-
ring physician or surgeon. How can this be acceptable? Imagine the graphically and sonographically. This is acceptable, yet, on a mam-
anguish. Is it any wonder that radiologists are the physicians most mogram with pleomor phic, linear casting-type calcifications, or
commonly named in malpractice lawsuits for delays in the diagno- clinically occult 6-mm spiculated mass, w e are e xpected to sa y
sis of breast cancer? I would argue that, in breast imaging, we are in “biopsy should be considered” or “appropriate action should be
taken”? Considered by whom and when? Appropriate action to be First, it is a patient’ s right not to w ant something done, and this
taken by whom and when? should always be respected and ne ver judged ne gatively. Second,
As a consultant, therefore, I e xercise the right to discuss all maybe if we worked harder to understand the patient’s concerns, we
aspects of a patient’s breast-related findings, options for diagnosi might be ab le to help her more ef fectively. Rather than close the
(and treatment when appropriate), and, most important, I make spe- door, leave it open so she feels she can walk back through it and you
cific recommendations and manage patients accordingl y. In con- will be there to help her . Try never to judge patients and w hat they
junction with the patient’s physician, I make referrals when indi- have chosen to do. Comments such as “How could she have let this
cated. Following biopsies, I provide all patients with m y business go?” or “Can you believe that she is saying this just came up?” are
card and cell phone number so the y can contact me if the y have not acceptable. Who are we to know what a patient is going through
questions or concerns, and I ask them to return the following busi- and what her reasons may be for making a decision? Little is accom-
ness day for the results of the biopsy. During the post biopsy visit, I plished, and I think we stand to lose much, by having a patient feel
examine the biopsy site and, most important, discuss the results of guilty about what she has chosen to do. Our job is not to judge her ,
the biopsy directly with the patient. I discuss all options with the but to help her toda y and put her in as positi ve a frame of mind as
patient, but I follow this with a specific recommendation for hat I possible to deal with what she is facing. I urge you to consider and
think is the next appropriate step. When indicated, and following a analyze everything that y ou say and do in approaching patients.
discussion with the patient’s physician, I make referrals so that the Work hard and creati vely to spin things in a positi ve light; rather
patient is helped and expedited through the system. Our patients are than viewing what we do as a chore, w e should vie w the tr ust
hungry for time, a w arm touch, infor mation, guidance, and y es, patients place in us as an incredib le privilege unlike few others
what we think is indicated. afforded us in life. We should feel honored that patients have enough
confidence in us to share some of their most personal infor mation,
fears, and concerns.
■ CONSIDERING YOUR APPROACH TO PATIENTS You set the tone for y our facility, and insisting that e veryone in
your facility think of patients as presenting with le gitimate con-
Consider how you approach patients. I suggest that proper attire, cerns and having the right to forgo a procedure has a positive effect
including a white coat with your name badge clearly visible, is crit- on how everyone approaches his or her job and our patients.
ical in sending a powerful message to patients. Scrubs belong in the
operating room or the interventional suite, not when approaching a
patient relative to a possible breast cancer diagnosis. Also, although ■ COMMUNICATION AND DOCUMENTATION
things like jeans and che wing gum ma y be acceptab le in recre-
ational venues, they are not when you are doing an ultrasound or an Lastly, I want to emphasize the need for communication and appro-
imaging-guided biopsy on a patient w ho is w atching you like a priate documentation. Communicate directl y with patients, refer-
hawk, waiting for some feedback. Address patients by their title and ring physicians, pathologists, surgeons, and medical oncolo gists.
last name; unless specifical y requested b y the w oman, patients Demand to speak directly with the physician (“I do not take no for
should not be addressed b y their first name, and te ms of endear- an answer.”). It is critical that refer ring physicians be kept in the
ment should not be used (this applies to the technolo gists as well). loop, particularly in relation to a breast cancer diagnosis in one of
Introduce yourself to the patient and shak e her hand. Before star t- their patients. Relative to pathology results, talk directl y with the
ing the examination, ask her one or tw o questions relative to her pathologist signing out a fine-needle aspiration or core biops . If
concerns. If the patient has been called back for a potential abnor- possible, visit the pathology lab and review the histology of some of
mality on the screening study, and you have done additional mam- the more interesting cases y ou may diagnose. These interchanges
mographic images, tell her w hat you have seen so f ar and explain can be incredibly valuable learning tools, and by working together,
what you would like to do next. If you are doing an ultrasound, let decisions can be made as to the adequac y of sampling or an y lin-
the patient watch the screen, and keep an eye on her. If she is watch- gering concerns the patholo gist may have that might alter y our
ing the screen as you scan, involve her in the study by educating her management of the patient. Discuss specimen radio graphy results
on what you are looking at. The ribs can be used to show her what directly with the sur geon while the patient is still in the operating
a “tumor” would look like. Try to make sure the patient understands room (e.g., are you concerned that a lesion may extend to the mar-
and is comfor table with w hat you recommend, and ne ver let an gins, or are you concerned that the lesion, or your localization wire,
angry patient leave your facility. Talk to her and find out hat you has not been excised?).
can do to make things better. I document the date, time, and nature of all communication (if
I think it is also impor tant to consider some of the language that possible with direct quotes) on the patient’s history form (not in the
permeates our work. Although this sounds tri vial, I think it ne ga- breast imaging consultation repor t). Invest time in teaching y our
tively colors our perspecti ve and helps impersonalize and distance clerical and technical staf f how to document encounters with
us from our patients. Consider terms such as “cases,” “complaints,” patients properly. Months or years down the road, appropriate doc-
“denies,” and “refuses.” Does it not subtl y affect us if w e view umentation can be critical in dealing with unresolved patient issues.
“cases as complainers w ho deny and refuse”? I see patients, not Documentation needs to be appropriate, factual, and nonjudgmental.
cases. Why do we choose to view what a patient presents with as a Documentation should not be a reflection of h w your employee
complaint? If you have a legitimate concern about something, does felt or sa w a situation b ut rather a nar rative of w hat happened.
it not bother you even slightly if someone says you are complaining Provide the information accurately and let the reader formulate the
about it? If you have legitimate fears about something and want time impression. These simple steps cost little and y et the re wards in
to think and consider your options, or if you are afraid, is this refus- good patient care, goodwill, and public relations can be significan
ing? Does it not turn us off when someone says, “She is refusing”? (as intangible as they may seem).
PATIENT 1
may be warranted at this time. Because this patient has no prior

What do you think, and what would you do next?
films, she is called back for additional evaluation, including spot
compression views, correlative physical examination, and sonog-
A mass is present in the right breast. Before recommending an y
raphy.
additional evaluation, you should inquire about prior f ilms. If
prior films are vailable, and this mass is stab le, decreasing in
size, or has been previously evaluated, no additional intervention
C Figure 3.1. (Continued) Spot compression paddle (C) used in my practice for
diagnostic evaluations.
thickness of the tissue requiring penetration. In e valuating spot

Why use a spot compression paddle, and what are the
compression views, it is impor tant to ensure that the area in ques-
indications for spot compression views? tion is included on the view; masses can sometimes be “squeezed”
What is critical to consider when evaluating the (or pulled) out from under the paddle and not imaged. As with rou-
adequacy of spot compression views? Why? tine views, spot compression views need to be well exposed, high in
contrast, and free of motion blur.
The spot compression paddle enab les the application of maximal
compression to a small area of the breast so that tissue is spread out
and the area of radio graphic concern is brought closer to the film When are rolled spot compression views used?
thereby improving resolution and image quality; it can help reach
areas that are otherwise dif ficult to include w hen the lar ge com- Rolled spot compression (i.e., change-of-angle) views are an addi-
pression paddle is used. Spot compression views are helpful in sev- tional tool available for establishing the existence of a lesion. Most
eral different situations in the diagnostic e valuation of patients. In tumors are three-dimensional and maintain their tumorlike shape as
some patients, spot compression vie ws are used to distinguish a tissue is rolled. In contrast, breast tissue and focal areas of
mass or distortion from normal superimposed glandular tissue. If a parenchymal asymmetry change in size, shape, and overall density
mass is detected on routine views, spot compression views can help as tissue is moved. Rolled spot compression views can also be used
characterize the marginal characteristics of the mass by displacing to move (roll) lesions away from surrounding tissue so that the mar-
obscuring superimposed tissue. ginal characteristics can be demonstrated to better adv antage (Fig.
In screening and diagnostic situations, spot compression vie ws 3.1D–F). Lastly, rolled spot compression vie ws can be used to
can be helpful in evaluating the subareolar area, particularly if com- establish the appro ximate location of a lesion in the breast. If a
pression of the anterior aspect of the breast is limited b y the thick- lesion is located in the medial aspect of the breast, it will move with
ness of the base of the breast. If there is an area of relati vely dense medial tissue. Similarly, if a lesion is in the lower outer quadrant of
tissue that is underexposed, using the spot compression paddle may the breast, it will move with the tissue in the lo wer outer quadrant
be helpful in improving the exposure by effectively decreasing the of the breast.
D
E
Figure 3.1. (Continued) Diagram of craniocaudal views (D) illustrating

a mass in the medial aspect of the right breast par tially obscured by sur-
rounding tissue. The tissue medial to the lesion is f atty, so if the lesion can
be moved away from the glandular tissue into the f atty tissue, the margins
may be better evaluated. On the diagram of the mediolateral oblique views
(E), the lesion is inferior in location. So, rolling inferior tissue medially may
move the lesion and sur round it with f atty tissue. Inferior tissue is rolled
F medially, and a spot compression vie w is done (F). The lesion is now sur-
rounded by fat so that more of the margins can be evaluated.
Figure 3.1. (Continued) Craniocaudal (G) and mediolateral oblique (H) spot compression views.
I J
Figure 3.1. (Continued) Ultrasound images (I, J) through separate portions of the lesion at the 7 o’clock position, 4 cm from the nipple in the longitu-
dinal (LON) projection.
Rather than just consider a biopsy, one is performed, and a com-

plex fibroadenoma is diagnosed. The patient is asked to return in 1
what differential would you consider? year for her next screening mammogram.
Complex fibroadenomas are defined as fibroadenomas with sup
The margins of this 1-cm mass are indistinct on the craniocaudal
imposed fibro ystic changes including cysts 3 mm in size, scleros-
spot compression view and more circumscribed on the mediolateral
ing adenosis, epithelial calcifications, and papilla y apocrine
oblique spot compression view. On ultrasound, this nearly isoechoic
changes. They can be anticipated when cystic changes are noted in an
oval mass is well circumscribed with posterior acoustic enhancement
otherwise well-circumscribed oval mass such as the one demon-
and associated cystic changes.
strated here, or when round, punctuate, or amor phous calcification
Benign diagnostic considerations include fibroadenoma (tu ular
are identified in an otherwise ell-circumscribed mass mammo-
adenoma, complex fibroadenoma), p yllodes tumor, pseudoan-
graphically (i.e., the punctate and amor phous calcifications refle
giomatous stromal hyperplasia (PASH), focal fibrosis, papilloma
the presence of sclerosing adenosis). In some patients, no distinctive
an inflammato y lesion, or , in cer tain clinical conte xts (recent
imaging features are identified to suggest a compl x fibroadenoma
trauma or sur gery), a hematoma. A granular cell tumor is a rare
These lesions are benign and do not warrant any additional interven-
possibility. Malignant considerations include invasive ductal carci-
tion following core biopsy. Approximately 33% of all fibroadenoma
noma not otherwise specifie , mucinous carcinoma, papillar y car-
have been reported as complex. When proliferative changes are pres-
cinoma, or a metastatic lesion. A biopsy is indicated.
ent in the stroma sur rounding a complex fibroadenoma, the risk o
BI-RADS® category 4: suspicious abnor mality, biopsy should
breast cancer has been reported to be increased 3.88 times.
be considered.
PATIENT 2
A B
Figure 3.2. Diagnostic evaluation, 50-year-old patient who presents describing a “lump” in her left breast. She was told at another imaging facility that her
mammogram and ultrasound are nor mal; she is adamant in w anting an e xplanation for w hat she feels. Craniocaudal (A) and mediolateral ob lique
(B) views, left breast.
may be deferred in patients in whom there is no chance the lesion

What is an appropriate approach to patients who
has been excluded from the field of vi w and completely fatty tis-
describe a localized concern (a “lump,” focal skin sue, or a benign lesion (oil c yst, dystrophic calcification, etc.), i
changes, pinpoint tenderness, etc.)? imaged corresponding to the area of concer n. Aspiration or core
biopsy may be indicated, depending on the clinical and imaging
For patients who are 30 years of age or older and who present with features of the lesion.
a palpable abnormality (or other localized finding), a metallic B
is placed at the site of the focal finding and a bilateral mammo
gram is done; a unilateral study of the symptomatic breast is done How would you describe the findings on the routine
if the patient has had a mammo gram within the last 6 months. A views of this patient, and with what degree of certainty
spot tangential view at the site of the focal abnormality is obtained can you make any recommendations?
in conjunction with the routine vie ws. In many patients, the tan-
gential view is helpful in either par tially or completely outlining Although there is a small island of tissue superimposed on the left
the lesion with subcutaneous fat, enabling better visualization and pectoral muscle in close pro ximity to the metallic BB , no definit
characterization of the lesion. If needed, additional spot compres- abnormality is apparent on the routine vie ws of the left breast. At
sion or spot compression magnif ication views can be done. this point, we have an inadequate amount of infor mation to make
Depending on the location of the focal finding, and the appearanc any justifia le recommendations. We need to re view the spot tan-
of this area on the spot tangential view, correlative physical exam- gential view of the “lump,” talk to the patient, undertake correlative
ination and an ultrasound are usuall y indicated. The ultrasound physical examination, and do an ultrasound.
Figure 3.2. (Continued ) Spot tangential (C) view,

palpable finding left breast. Ultrasound image in th
radial (RAD) (D) projection at the site of the palpab le
D finding in the left breast
ment is identified at the 12 o’clock position, 8 cm from the left nipple

corresponding to the palpab le abnormality. Although the finding i
subtle on ultrasound, with careful and meticulous technique it is dis-
A 7-mm spiculated mass associated with punctate, low-density calci-
cernable and reproducibly imaged as the palpable area is scanned. In
fications is imaged on the spot tangential vie w corresponding to the
positioning patients for the ultrasound study , I try to thin the area of
palpable finding.A discrete, hard mass is palpated at the site indicated
the breast being e valuated as much as possib le. In evaluating lateral
by the patient in the left breast. She has not had a prior biopsy or
lesions, the patient is placed in an oblique position with a wedge under
trauma to this site, and no tenderness is elicited on palpation. On ultra-
the ipsilateral arm, and for medial lesions she is supine. If the patient
sound, a small hypoechoic mass with disr uption of the Cooper liga-
says she feels the “lump” more when she is upright, I will palpate and changes are noted in the sur rounding stroma and probably explain
scan the area with her sitting as well as lying down. During the ultra- the imaging features of these lesions (i.e., spiculation).Tubular car-
sound study, I hold the transducer with my right hand and I place the cinomas may be difficult to distinguish from radial scars/comple x
pads of my left index, ring, and middle fingers at the leading edge o sclerosing lesions (in some patients, tubular carcinomas arise in
the transducer so that I am palpating the tissue as I rotate and mo
ve the radial scars/complex sclerosing lesions), sclerosing adenosis, and
transducer with my right hand. I apply varying amounts of compres- microglandular adenosis. Special immunohistochemical stains are
sion as I manipulate the transducer directly over the area of clinical or sometimes needed to assess the presence of m yoepithelial cells.
mammographic concern. These tumors are often diploid, estrogen- and progesterone-receptor-
positive, and only rarely over-express HER-2 neu.
What is your differential diagnosis, and what

recommendation should you make to the patient? Why is listening, correlating physical and imaging
findings, and establishing rapport with your patients so
Differential considerations for the findings include i vasive ductal important?
carcinoma not otherwise specified (NOS), tubular carcinoma, an
invasive lobular carcinoma. Benign considerations include f at Complete, thoughtful e valuations are indicated for all patients, but
necrosis (posttrauma or postsur gery), sclerosing adenosis, papil- particularly those presenting with focal signs and symptoms.
loma, focal fibrosis, a compl x sclerosing lesion, and inflammato y Radiologists as a group are the most commonly sued physicians, and
changes (mastitis). Other rare benign causes include g ranular cell delays in the diagnosis of breast cancer are the most common causes
tumor or an extra-abdominal desmoid. of malpractice claims filed. Interesting y, the suits are not usuall y (at
A biopsy is indicated. least not yet) for missing subtle mammo graphic findings, but rathe
BI-RADS® category 4: suspicious abnor mality, biopsy should for clinically apparent findings the patient feels ere ignored. I urge
be considered. you to establish a good rapport with your patients, listen to their con-
An ultrasound-guided biopsy is done, and an invasive mammary cerns, and make every effort possible to help them. Not onl y is this
carcinoma with features suggesti ve of tubular carcinoma is good medicine, it makes for a rewarding and fulfilling practice oppor
described on the core samples. A tubular carcinoma is confi med tunity. You do not want patients leaving your facility angry and feeling
following the lumpectom y. Sampled l ymph nodes are nor mal that their concerns were ignored or not adequately evaluated. Do not
(pT1b, pN0, pMX; Stage I). short-circuit appropriate and logical mammographic workups. Make
sure that what is seen mammographically correlates with the clinical
findings. In making sure that w hat is seen on ultrasound cor relates
In considering tubular carcinoma, what associated with the mammographic findings ou are evaluating, determine the
lesions may be seen and what should you look for expected clock position of the lesion and its appro ximate distance
mammographically? from the nipple before going into the ultrasound room; this location
should be the starting point for the ultrasound study.
The reported incidence of tubular carcinomas varies depending on While examining the patient and cor relating clinical, mammo-
detection method, tumor size, and the definition used to classif graphic, and ultrasound findings, I obtain a more detailed histo y
these tumors. Pure tubular carcinomas probab ly represent 1% to from the patient. This is also a good time to con vey to the patient
2% of all breast cancers. Tubular carcinomas are usuall y detected what I am doing on her behalf, to discuss recommendations, deter-
mammographically as a small spiculated mass; less commonl y, mine if the patient is comfor table with my recommendations, and
patients present with a palpab le mass. Associated round, punctate, answer her questions. Although some consider it inef ficient for a
and amorphous calcifications m y be seen, reflecting the presenc radiologist to do the ultrasound studies personally, I argue that it is
of low-nuclear-grade ductal carcinoma in situ (solid , cribriform, more efficient and it ma es for good patient care.
and micropapillary), in an a verage of 65% of patients. Satellite During the real-time scan, and before taking an y images, I deter-
lesions may also be seen, because these lesions ma y be multifocal mine if there is an identifia le abnormality by examining the patient as
or multicentric in 10% to 20% (repor tedly as high as 56% in one I rotate the transducer and apply varying amounts of compression over
small series) of patients. Lobular neoplasia (lobular carcinoma in the area of concern. The 360-degree rotation of the transducer is criti-
situ), contralateral invasive ductal carcinomas NOS, and a histor y cal in excluding pseudolesions created b y areas of f atty lobulation,
of breast cancer in a first-d gree relative have been reported in as which in one plane may look round or oval but elongate and fuse with
many as 15% (range 0.7% to 40%), 38%, and 40% of patients diag- surrounding tissue as you rotate the transducer. A real mass maintains
nosed with tubular carcinoma, respectively. a round or o val shape as y ou rotate the transducer directl y over it.
Applying variable amounts of compression over an area can help elim-
inate critical angle shadowing that may limit the evaluation of deeper
What distinguishes the glands seen in tubular tissue. If I determine that a lesion is present, I take orthogonal images
carcinomas from normal glands? (with and without measurements) that demonstrate representative fea-
Histologically, what are the differential considerations tures of the lesion. In some women, this may require radial and antira-
for this lesion? dial projections, whereas in others, transv erse and longitudinal (i.e.,
sagittal) orientations show the lesion and its characteristics to better
Histologically, these lesions are characterized b y the presence of advantage. I use the images tak en to support my impression and jus-
oval and round, open tubules some with angulation. The glands in tify my recommendations. I take no images of normal tissue. In anno-
tubular carcinomas are lined by a single epithelial cell layer and, in tating the images, the breast being scanned is indicated, as is the clock
contrast to nor mal glands, lack m yoepithelial cells. Desmoplastic position of the lesion and its distance in centimeters from the nipple.
PATIENT 3
Figure 3.3. Diagnostic evaluation, 80-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and
C Figure 3.3. (Continued) Spot tangential (C) view taken of the palpable findin
(metallic BB on palpable finding)
whom there is no chance the lesion has been excluded from the tan-
What is an acceptable approach to patients who
gential view and completel y fatty tissue, or a benign lesion, is
present with focal findings? imaged corresponding to the palpable abnormality.
In evaluating the adequacy of spot tangential views, In this patient, do you see the metallic BB on the routine views of
what should you consider? the right breast? Why not? In this patient, the palpab le finding i
deep in the breast, just abo ve the inframammary fold. The metallic
In patients who are 30 years of age or older and who present with a BB was placed on the “lump” but has been e xcluded from the fiel
palpable abnormality (or other localized finding), a metallic BB i of view. The metallic BB is seen on the spot tangential view, and pre-
placed at the site of concern, and routine views are done bilaterally dominantly fatty tissue is imaged on the spot tangential view. In this
unless the patient has had a mammo gram in the preceding 6 patient, the possibility that the lesion has been e xcluded from the
months, in w hich case a unilateral mammo gram of the sympto- images is a real concer n. As with all spot compression vie ws, you
matic breast is done. In addition, a spot tangential view of the focal need to consider the possibility that the lesion has been squeezed out
finding is done. In man y patients, the tangential vie w is helpful in of the field of vi w or, because of its location, is not included on the
either partially or completel y outlining the lesion, with subcuta- images. Correlative physical examination in this patient confi ms
neous fat facilitating characterization. Depending on the location of the presence of a palpab le mass fi ed at the inframammar y fold.
the focal finding, and the appearance of this area on the spot tan Also noted are ar terial calcifications in the left breast and coarse
gential view, correlative physical examination and an ultrasound dense, benign-type calcifications anterior y in the right breast.
are usually indicated. Ultrasound ma y be defer red in patients in
D E
Figure 3.3. Ultrasound images (D, E) of the palpable mass at the inframammary fold of the right breast in an antiradial (ARAD) projection.
or spot compression views of the breast. Anytime you suspect that a

How would you describe the ultrasound findings, and
lesion is potentially excluded from the mammo graphic images, or
what is indicated in this patient?
there are potential factors limiting compression, correlative physical
examination and ultrasound are w onderful adjunctive tools. Also,
A round, 1.2-cm hypoechoic mass with partially indistinct margins
capitalize on basic concepts such as the use of various projections to
and associated posterior acoustic enhancement is imaged cor re-
position tissue as close to the film as possi le. If you think a lesion
sponding to the palpable finding at the 6 o’clock position, posteri
is medial in location, consider a 90-de gree lateromedial (LM) spot
orly (Z3) in the right breast. The lesion is just belo w the skin and
compression so that medial tissue is placed up against the film; thi
snuggled in close proximity to the ribs (R). An invasive ductal car-
minimizes the possibility of e xclusion because medial tissue is up
cinoma not otherwise specifie , mucinous carcinoma, papillar y
against the film, and it impr ves resolution by placing the area of
carcinoma, or a metastatic lesion are the primary considerations in
concern closest to the film. Li ewise, if you think a lesion is high up
an 80-year-old patient presenting with these findings.
in the breast, have the technologist do a from-below (FB) view such
that superior tissue is now closest to the film. If ou suspect a lesion
be considered.
is at, or just below, the inframammary fold (IMF), tell the technolo-
A mucinous carcinoma is diagnosed on the ultrasound core
gist not to lift the breast as she positions for the craniocaudal (CC)
biopsy. A 1.3-cm mucinous carcinoma with associated inter medi-
view. She should place the film holder at the neutral position for th
ate-grade ductal carcinoma in situ is confi med on the lumpectomy
IMF, because as the breast is lifted at the IMF for the routine CC
specimen. The sentinel lymph node is ne gative for metastatic dis-
view, the mass ma y be able to slip out and not be included on the
ease (pT1c, pN0(sn) (i), pMX; Stage I).
image. Remember, the use of the spot compression paddle usuall y
makes it easier to include more posterior, superior, or axillary tissue
What are some of the tools available in evaluating in the field of vi w. In evaluating potential lesions in the axillary tail,
lesions possibly excluded from the routine views? an axillary view can be useful.
Lesions close to the chest w all (far superior, inferior, lateral, or

medial) and lesions high in the axilla may not be included on routine
PATIENT 4
A
B
Figure 3.4. Diagnostic evaluation, 62-year-old woman called back for

C calcifications detected in the right breast on her screening study . Double
spot compression magnification vi ws (A–C) of calcifications, right breast
onal projections to e valuate women with indeter minate calcifica

What is an appropriate evaluation of patients with
tions detected on routine mammographic views.
screening-detected calcifications that cannot be
classified as benign on the routine views?
The next step should be magnification vi ws. Specifical y, our pro-

tocol uses double spot compression magnification vi ws in orthog-
Figure 3.4. Setup for double spot compression magnification vi ws (D). A

Lexan® top magnification stand is used to minimize the amount of radiatio
absorbed by the stand itself. The built-in spot compression is combined with a
spot compression paddle to obtain double spot compression of the tissue being
evaluated. By reducing the amount of radiation absorbed b y the magnificatio
stand, maximizing compression by applying from above and below the lesion,
D and making adjustments in kilovoltage, well-exposed, high-contrast magnifica
tion views with no motion artifact can be obtained routinely.
breathing are simple steps that can impro ve overall image quality
How is magnification obtained, and what are the
significant y.
resulting effects? As a general rule, the voltage used for exposure on magnificatio
views is increased by 2 kV over that used for the routine, nonmagni-
Magnification technique is accomplished by increasing the distance
fied views. We do all of our magnification vi ws using a Lexan®-top
between the breast (i.e., object) and film.The resulting air gap helps
magnification stand (MammoSpot®, American Mammographics,
to eliminate scatter radiation, so a grid is not needed for magnifica
Chattanooga, TN). Compared to standard carbon-top magnificatio
tion views. Compared with the 0.3-mm focal spot used for routine
stands, those made of Le xan® absorb less radiation, so e xposure
(nonmagnified) mammographic views, a 0.1-mm focal spot is used
times can be decreased by as much as 40%.
for magnification vi ws. The small focal spot is needed to minimize
Optimal compression is also critical for obtaining high-quality
the penumbra effect that results as you increase the breast (object)-
magnification views. This is w hy we advocate the use of doub le
to-film distance. The use of the small focal spot, however, results in
spot compression. The magnification stand has a built-in spot com
increased exposure times, so motion becomes a significant issu
pression, which, when combined with the spot compression paddle,
that may limit the usefulness of magnification vi ws.
enables maximal compression of the tissue being e valuated (i.e.,
double spot compression). The technologist is also encouraged to
What can be done to minimize the likelihood of motion work with the patient on breath holding (i.e., the patient should stop
blur on magnification views? breathing when requested rather than taking a deep breath in) to
minimize the likelihood of motion.
Optimizing the system to obtain an adequate e xposure in a shor t If you have determined that there is a need for magnificatio
period of time is critical for routinel y obtaining high-quality mag- views, don’t settle for suboptimal quality and hide behind dis-
nification views. An appropriate selection of v oltage, a magnifica claimers. If the magnification vi ws are not optimal, step back and
tion stand that minimizes the amount of radiation absorbed, optimal review what the technologist is doing. Does the v oltage need to be
focal compression, and working with the patient on controlling her increased further (accepting that as you increase voltage, contrast is
decreased)? Is the cor rect focal spot being used? Can compression tion views. The differential is limited b ut includes fibro ystic
be increased? Can you work with the patient to improve breath hold- changes including columnar alteration with prominent apical snouts
ing? High-contrast, well-exposed, artifact-free magnification vi ws (CAPPS), ductal hyperplasia and atypical ductal hyperplasia, fibro
are critical for assessing the morphology and extent of calcification sis, and ductal carcinoma in situ. In the absence of any other change
that may reflect the presence of ductal carcinoma in situ. Rec gnize related to trauma (e.g., mix ed-density mass, oil c yst), or a specifi
that the ability to detect and characterize calcifications and smal history of trauma or sur gery to the site of the calcifications, thes
masses is significant y compromised (and ma y be eliminated) on calcifications are unlikely to represent an early stage of fat necrosis.
images with blurring. Given the linear orientation of the calcifications, biopsy is indicated
be considered.
How would you describe these calcifications in this Ductal carcinoma in situ is repor ted on the stereotacticall y
patient, and what is your differential diagnosis? guided biopsy and confi med on the lumpectomy [Tis(DCIS), pNX,
What is indicated? pMX; Stage 0].
Round, punctate, and linear calcifications demonstrating linear ori

entation are confi med on the doub le spot compression magnifica
PATIENT 5
(B) views.
pression view in the MLO projection is obtained. If no abnor mal-

What do you think, and what is your recommendation
ity persists on the spot compression view, no additional views are
at this point? done; if a question remains, rolled spot compression views can be
done. In this patient, a 1.2-cm mass with indistinct margins is con-
Arterial calcifications are present bilateral y. A possible mass is
fi med on the MLO spot compression vie w (Fig. 3.5C). We must
present on the right mediolateral ob lique (MLO) vie w superim-
now establish the location of this abnormality in the CC projection
posed on the pectoral muscle inferiorl y. This should be distin-
using a logical approach. We make no assumptions as to the lat-
guished from se veral well-circumscribed, mixed-density masses
eral, central, or medial location of the lesion on the CC vie w.
(i.e., lymph nodes) superimposed on the pectoral muscles, bilater-
Rather, a 90-de gree lateral view (usually a lateromedial vie w) is
ally. No definite co responding abnormality is apparent on the right
done to determine how this lesion moves with respect to its location
craniocaudal (CC) view. Comparison with prior studies is the start-
on the MLO view. If the lesion moves up, it is located medially and
ing point. If no prior films are vailable, or if this potential mass
a spot clea vage view is done; if the lesion mo ves down, it is
represents a change, additional evaluation is indicated.
located laterally such that a spot craniocaudal vie w exaggerated
laterally is done; and if it does not move significant y, the lesion is
central in location and a spot compression vie w directly behind
How would you approach the diagnostic evaluation of the nipple is obtained. In this patient the lesion mo ves up (image
this patient? Be specific in describing the steps you not shown), consistent with a medial location. Upon fur ther
review of the CC view, a density is partially noted on the cranio-
would follow.
caudal view at the edge of the film medial y (box, Fig. 3.5D). A
follow-up image with the spot compression paddle enab les visu-
When a potential abnormality is seen in only one of the two stan-
alization of more tissue so that the lesion is imaged in its entirety
dard views, we start by determining if the finding is real in th
(Fig. 3.5E) in the CC projection.
view in which it is initially perceived. In this patient, a spot com-
Figure 3.5. (Continued ) Mediolateral ob lique (C) spot compression vie w

confi ms the presence of a mass with indistinct and spiculated mar gins in the
right breast. On a 90-de gree lateromedial (LM) vie w (not shown), the lesion
C moves up with respect to its position on the mediolateral ob lique view, consis-
tent with a medial location for the lesion.
Figure 3.5. (Continued ) Further review of the

craniocaudal (D) views demonstrates a possib le
mass at the edge of the right craniocaudal vie w
medially (box). Spot compression (E) view of the
medial aspect of the right breast in the craniocaudal
projection demonstrates a mass with indistinct and
spiculated margins. Some punctate calcification
may be present. Pectoral muscle is now also seen at
the edge of the spot compression vie w posteriorly.
The spot compression paddle often enab les visuali-
E zation of otherwise hard-to-reach areas such as the
upper inner quadrants posteriorly
F G
Figure 3.5. (Continued) Ultrasound images, upper inner quadrant, right breast, in radial (RAD) (F) and antiradial (ARAD) (G) projections.
ting the deep pectoral fascia (arrowheads, Fig. 3.5H). Straightening,

thickening, and disruption of Cooper ligaments are noted.This mass
corresponds to the mass seen mammographically.
An irregular, 1.2-cm mass with indistinct, angular , and spiculated
margins is imaged at the 1 o’clock position posteriorl y (Z3), abut-
Figure 3.5. Ultrasound image (H) in the antiradial (ARAD) projection at the
H 1 o’clock position of the right breast, posteriorl y, demonstrating gentle mass
effect on the deep pectoral fascia (arrowheads).
sentinel lymph node biopsy. The lymph node is sectioned and the
What is your differential diagnosis, and what
cut edge is blotted on slides. The cytologic material on the slides is
recommendation do you make to the patient? fi ed, stained, and reviewed by the pathologist. If malignant cells
are identified on the touch imprints, a complete axilla y lymph
Differential considerations include in vasive ductal carcinoma not
node dissection is done at the time of the lumpectom y. However,
otherwise specifie , invasive lobular carcinoma, or l ymphoma.
metastatic disease is not e xcluded if the imprints are repor ted as
Rarely, ductal carcinoma in situ can present as a mass, asymmetric
benign; false-negative touch imprints are commonl y associated
density, or distortion in the absence of microcalcifications. Benig
with invasive lobular carcinoma. In patients in whom the imprint is
considerations include an inflammato y process or posttraumatic
negative but metastatic disease is identif ied in the per manent,
changes, focal fibrosis, a papilloma, sclerosing adenosis, pseudoan
hematoxylin and eosin–stained sections of the sentinel l ymph
giomatous stromal h yperplasia, granular cell tumor , or an e xtra-
node, a full axillar y dissection is usuall y undertaken as a second
abdominal desmoid. Gi ven the imaging features of this lesion, a
operative procedure.
biopsy is indicated.
be considered. How is an extensive intraductal component defined,
An ultrasound-guided biopsy is done. An invasive ductal carci- and what is its significance?
noma with associated ductal carcinoma in situ is diagnosed on the
core biopsy. An extensive intraductal component (EIC) is described w hen an
A 1.5-cm, grade I invasive mammary carcinoma, with apocrine invasive ductal carcinoma has a prominent intraductal component
differentiation and an associated e xtensive, intermediate-grade within it or intraductal carcinoma is present in sections of otherwise
(solid, cribriform patterns) ductal carcinoma in situ is repor ted on normal adjacent tissue. This term also applies to lesions that are
the lumpectomy specimen. Malignant cells are reported on a touch predominantly intraductal but ha ve foci of in vasion. An EIC may
imprint of the sentinel l ymph node done intraoperati vely. Twenty indicate the presence of residual disease 2 cm be yond the primary
additional nodes removed at the time of the lumpectomy are nega- lesion in as man y as 30% of patients and is associated with an
tive for metastatic disease (pT1c, pN1a, pMX; Stage IIA). increased incidence of local recurrence following breast-conserving
surgery and radiation therap y. Patients with tumors characterized
by an extensive intraductal component ma y benefit from a wide
What are touch imprints, and how are they used at the
resection. Tumors with EIC are repor tedly more common in
time of the lumpectomy and sentinel lymph node younger women.
biopsy?
Touch imprints of the e xcised sentinel l ymph node(s) are com-

monly done intraoperati vely at the time of the lumpectom y and
PATIENT 6
A B
Figure 3.6. Diagnostic evaluation, 49-year-old patient presenting with two

“lumps” in the right breast. Craniocaudal (A) and mediolateral oblique (B)
C views, right breast; metallic BBs used to mark “lumps. ” Spot compression
(C) view (orthogonal view not shown), right breast.
reflect the same or, possibly, different processes. Cyst(s), fibroade

How would you describe the two masses?
noma(s), tubular adenoma(s), ph yllodes tumor(s) papilloma(s),
What would you do next? pseudoangiomatous stromal h yperplasia (PASH), focal fibrosis
abscess(es), posttraumatic or postsur gical fluid collections, i va-
Two masses are present in the right breast, cor responding to the
sive ductal carcinoma(s), medullary carcinoma(s), mucinous carci-
“lumps” described by the patient. The margins of the anterior mass
noma(s), papillary carcinoma(s), and metastatic lesion(s) are
are well circumscribed on the spot compression vie ws (only one
included in the dif ferential. Correlative physical examination and
shown). In comparison, the mar gins of the lar ger, posterior mass
an ultrasound are indicated for fur ther characterization of these
are not as shar p and, for a por tion of the mass, are indistinct. In
lesions.
entertaining a dif ferential, you need to consider that these ma y
view, the posterior mass is located in the upper inner quadrant of

Although these masses are palpable, based on their
the right breast at the 2 o’clock position, 8 cm from the nipple, and
location on the mammogram, at what clock position do measures 3 cm. It is vertically oriented, markedly hypoechoic, with
you expect to find these lesions? Be specific. indistinct margins and some spiculation. Some posterior acoustic
enhancement is present. The imaging features of the anterior mass
The anterior mass is located at the 12:30 o’clock position, 4 cm suggest a benign process and those of the posterior mass suggest a
from the right nipple. It is a 1.2-cm o val, well-circumscribed mass malignancy. Biopsies are recommended for both lesions.
characterized by areas of enhancement and shado wing. Although BI-RADS® category 4: suspicious abnor mality, biopsy should
projecting below the level of the nipple on the mediolateral oblique be considered.
D E
Figure 3.6. Ultrasound image (D) of anterior mass, antiradial (ARAD) projection, and ultrasound image (E) of posterior mass, ARAD projection.
A complex fibroadenoma is repo ted histologically for the ante- what is seen on the mammogram and anything that may be found on
rior mass. An invasive mammary carcinoma is diagnosed for the the ultrasound study. The information on the CC and MLO vie ws
posterior lesion. A 4-cm, metaplastic carcinoma with no heterolo- (taken with the patient upright and tissue pulled out a way from the
gous elements and a nor mal sentinel l ymph node biopsy are body) needs to be transposed to a patient w ho is now supine, or in a
reported following surgery [pT2, pN0(sn) (i), pMX, Stage IIB]. slight oblique position, for the ultrasound study . Approximating the
As you progress from the mammogram to doing the ultrasound, clock position of a lesion in the breast can be af cilitated (and learned)
consider carefully and focus y our attention on the anatomic loca- by using frontal diagrams of the breast, in conjunction with the loca-
tion of the lesion being evaluated. Obviously, it is critically impor- tion of the lesion on the CC and MLO views.
tant to assure that the lesion seen on the mammo gram correlates On a frontal diag ram of the breast, the posterior nipple line
with what you find on the ultrasound stud . To this end, review the (PNL) is drawn as extending from the upper inner quadrant to the
mammographic images before scanning the patient, so that w hen lower outer quadrant of the breast, transecting the nipple (this
you walk in to e valuate the patient y ou have the e xpected clock defines the course of the x-ray beam when an MLO view is done).
position and approximate distance from the nipple for the lesion Next, reference the location of the lesion on the MLO vie w (Fig.
being evaluated as your starting point. 3.6J) with respect to the PNL. The lesions are ho w far above or
On craniocaudal and 90-de gree lateral views (LM and ML), the below the posterior nipple line on the MLO vie w? The lines
location of a lesion is anatomic with respect to the nipple. Medial, describing the location of the lesion, with respect to the PNL on the
lateral, and central findings on craniocaudal vi ws are located medi- MLO view, are drawn on the frontal diagram (Fig. 3.6K). Using the
ally, laterally, and centrall y (i.e., behind the nipple) in the breast. location of the lesions on the CC view (Fig. 3.6L), you can now nar-
Superior and inferior findings with respect to the nipple are located i row down the clock location of the lesion along the course of the
the upper and lower quadrants, respectively, on the 90-degree lateral lines drawn on the frontal view (Fig. 3.6J). You can now walk into
view (Fig. 3.6F). On mediolateral ob lique views, however, it is the ultrasound room and place the transducer at the expected clock
important to recognize that some lesions projecting below the level of position for each lesion and find them easiy with the assurance that
the nipple are in an upper quadrant of the breast and some that project what you are imaging on ultrasound cor relates with what is being
above the level of the nipple are in a lower quadrant (Fig. 3.6G–I). seen mammographically.
Based on the CC and MLO vie ws, the anatomic location of the
lesion needs to be determined, to assure accurate correlation between
G
F
Figure 3.6. Frontal diagram (F) of the right breast, illustrating the course of the x-ray beam for craniocaudal, lateral, and mediolateral oblique views. On
craniocaudal views, the location of lesions is anatomic: those projecting laterally or medially are in the lateral and medial aspects of the breast, respectively.
Similarly, on true lateral views, lesions projecting superiorly or inferiorly are located in the upper or lower quadrants, respectively. On mediolateral oblique
views, however, some of the tissue that projects above the level of the nipple is inferior to the nipple (G), and some tissue projecting below the level of the
nipple is superior to the nipple (H).
H I
Figure 3.6. (Continued) Frontal diagram (F) of the right breast, illustrating the course of the x-ra y beam for craniocaudal, lateral, and mediolateral
oblique views. On craniocaudal views, the location of lesions is anatomic: those projecting laterally or medially are in the lateral and medial aspects of the
breast, respectively. Similarly, on true lateral views, lesions projecting superiorly or inferiorly are located in the upper or lower quadrants, respectively. On
mediolateral oblique views, however, some of the tissue that projects above the level of the nipple is inferior to the nipple (G), and some tissue projecting
below the level of the nipple is superior to the nipple (H). Consequently, on a mediolateral oblique (I) view, some lesions projecting above the level of the
nipple (gray triangle, “A”) are anatomically in the lower outer quadrant, and some lesions projecting below the level of the nipple (black triangle, “B”) are
anatomically in the upper inner quadrant of the right breast.
J K
Figure 3.6. (Continued) Diagrams illustrating (Eklund , p.c.) ho w to

determine the approximate clock position of the lesions based on the cra-
niocaudal and mediolateral ob lique views of the cur rent patient. On the
mediolateral oblique view (J), determine the location of the lesion relati ve
to the posterior nipple line (i.e., how far above or below the posterior nipple
line the lesion is located). The location of the lesions relati ve to the poste-
rior nipple line is transposed to the frontal diag ram (K). Now use the cra-
L niocaudal view (L) to determine whether the lesion is medial, lateral, or
central in location.
PATIENT 7
A B
Figure 3.7. Diagnostic evaluation, 82-year-old patient presenting with a “lump” in the left breast. Craniocaudal(A) and mediolateral oblique (B) views pho-
tographically coned to the area of concern in the left breast. Metallic BB (arrows) indicate the location of the palpable mass.
When women who are over the age of 30 y ears present with a
At this point, what can you say and with what degree of
“lump” or other focal symptom (focal pain, skin change etc.), a
certainty? metallic BB is placed at the site of focal concern. This is followed
What else would you tell the technologist to do? by craniocaudal and mediolateral ob lique views, bilaterally, as
well as a spot tangential view of the focal abnormality (a unilateral
Scattered and some clustered round and punctate calcifications, a study of the symptomatic breast is done if the patient has had a
well as more dense, coarse, and some lucent-centered calcifica mammogram within the last 6 months). Based on these initial
tions, are present. However, no definite abno mality is apparent on images, additional spot compression or doub le spot compression
the craniocaudal and mediolateral ob lique views that cor responds magnification views may be done. Depending on the location of
to the site of concer n to the patient. At this point, we have insuffi the focal finding, and the appearance of this area on the spot tan
cient information to say anything definit ve. A spot tangential view gential view, correlative physical examination and an ultrasound
of the palpable finding m y be helpful; if it is not, correlative phys- are usually indicated.
ical examination and an ultrasound are indicated.
Figure 3.7. Spot tangential (C) view of palpab le finding in the l wer
inner quadrant of the left breast.
D
Figure 3.7. Ultrasound image (D) of the palpable finding in the l wer
inner quadrant of the left breast, in the antiradial (ARAD) projection.
How helpful is the tangential view of this patient? How would you describe the ultrasound findings?
At this point, what can you say and with what degree What is your leading diagnosis, and what is your
of certainty? recommendation?
What BI-RADS® assessment category would you
assign? On physical examination, a discrete, hard mass is palpated in the
lower inner quadrant of the left breast. There are no findings to sug
For this patient, the tangential view is helpful. A spiculated mass is gest an ongoing inflammato y process (e.g., no er ythema, tender-
now readily apparent, corresponding to the palpable finding. Unles ness, or w armth over the palpab le finding). An irregular, 1.5-cm
the patient has had trauma, or surgery localized specifical y to this hypoechoic mass with indistinct and angular margins and shadow-
area, or there are symptoms related to an inflammato y process, a ing is imaged on ultrasound at the 8 o’clock position, 6 cm from the
biopsy is indicated and the likelihood of malignancy in an 82-year- left nipple, cor responding to the palpab le finding. The clinical,
old patient is high. The patient has no history of breast-related sur- mammographic, and ultrasound findings are high y suggestive of a
gery or trauma. malignancy. Differential considerations include invasive ductal car-
cinoma not otherwise specified (NOS), tubular carcinoma, or i va-
sive lobular carcinoma. Although it is uncommon, ductal carci-
Is an ultrasound indicated in this patient for the noma in situ can present as a mass, asymmetry density, or distortion
purposes of evaluating the lesion? If not, why do an in the absence of microcalcifications. If there ere a histor y of
ultrasound? trauma or surgery localized specifical y to this spot, this could rep-
resent an area of fat necrosis. Rarely, in the appropriate clinical set-
Given a spiculated mass and no histor y of surgery or trauma, or ting, this could represent an inflammato y process.
symptoms related to an inflammato y process, corresponding to the BI-RADS® category 4: suspicious abnor mality, biopsy should
site of concern to the patient, a biopsy is indicated regardless of the be considered.
ultrasound findings. An ultrasound is done to deter mine if the Rather than just consider a biopsy, one is done using ultrasound
lesion can be imaged so that the biopsy can be done e xpeditiously guidance. An invasive ductal carcinoma (NOS) is diagnosed on the
using ultrasound guidance. Ultrasound-guided core biopsies are core biopsy. A 1.5-cm grade II invasive ductal carcinoma NOS is
better tolerated b y patients, par ticularly elderly patients, because confi med on the lumpectomy specimen. No metastatic disease is
the patient is supine as opposed to prone (with her neck tur ned all diagnosed on the sentinel lymph node [pT1c, pN0(sn) (i), pMX;
the way over to one side) on the dedicated stereotactic table, or sit- Stage I].
ting, if an add-on de vice is used. No breast compression or radia-
tion is required when the biopsy is done using ultrasound guidance.
Additionally, because or thogonal images of the needle can be What are the clinical and imaging features related to
obtained following firing of the needle during the biops , it is eas- invasive ductal carcinoma NOS?
ier to verify that the needle has gone through the mass. This is in
contrast to the unidimensional postfire images of needle position Invasive ductal carcinoma NOS is the most common breast malig-
ing during a stereotactically guided biopsy. nancy diagnosed in approximately 65% of all patients with breast
cancer. Depending on tumor size, location, and breast size, the

What are the more common subtypes of invasive
lesion may be palpab le, or skin thick ening or dimpling ma y be
ductal carcinomas, and what are their clinical and
noted clinically. Subareolar lesions may be associated with nipple
retraction, inversion, or displacement. A spiculated mass is the imaging features?
most common mammo graphic finding in patients with i vasive
ductal carcinoma NOS. Associated pleomorphic calcifications Tubular, medullary, mucinous, and papillary carcinomas are some of
reflecting the presence of ductal carcinoma in situ, are sometimes the more common subtypes of in vasive ductal carcinoma. Of these
seen in the mass or extending away from it for variable distances. If four subtypes, tubular carcinoma is the onl y one that presents as a
there are associated calcifications, it is impo tant to characterize small spiculated mass; in some patients, multiple small spiculated
them and describe their extent. masses may be identified. Medulla y carcinoma usually presents in
A round or o val mass with obscured , indistinct, or ill-define premenopausal woman as a round or oval mass and is characterized
margins is a less common mammographic presentation for invasive by rapid growth; many of these patients present with interval cancers
ductal carcinoma NOS. On ultrasound , these lesions are round or (within a year of a normal screening mammogram). Medullary carci-
oval, solid, hypoechoic masses with well-circumscribed or partially noma can be markedly hypoechoic on ultrasound (simulating a cyst).
indistinct margins; many have posterior acoustic enhancement. Mucinous and papillary carcinomas usually present as round or oval
Some may be markedly hypoechoic. Alternatively, a complex cys- masses in older, postmenopausal women and are usuall y character-
tic mass may be seen. When they present as a round or o val mass, ized by slower growth patterns. Ultrasound can be helpful in distin-
invasive ductal carcinomas NOS are often rapidl y growing, poorly guishing among some of the mucinous and papillar y carcinomas.
differentiated lesions, particularly if the lesion is solid and associ- Mucinous lesions are commonly iso- to slightly hypo- or hyperechoic
ated with posterior acoustic enhancement on ultrasound. In lesions and may have posterior acoustic enhancement. Papillary carcinomas,
with cystic changes on ultrasound , necrosis is commonl y present particularly those arising in the subareolar area, are often comple x
histologically. cystic masses with posterior acoustic enhancement.
PATIENT 8

corresponding asymmetric area, mediall y in the right breast (F ig.

Is this a normal screening mammogram, or do you
3.8D), on the craniocaudal view? What would you do next?
perceive a potential abnormality? BI-RADS® category 0: need additional imaging e valuation.
Spot compression views, correlative physical examination and an
Remember to focus y our attention b y splitting the images into
ultrasound are indicated.
thirds. On the oblique views, focus your attention on the lower third
of the breasts (Fig. 3.8C); now do you see something? Do you see a
Figure 3.8. (Continued) Mediolateral oblique (C) views with a box helping to focus attention on the lo wer
thirds of breasts. Craniocaudal (D) views with a bo x to help focus attention on the medial quadrants of the
breasts.
Figure 3.8. (Continued ) Spot compression

F views, craniocaudal (E) and mediolateral ob lique
(F) projections.
localized to this specific area, this finding requires biop . Although

a biopsy is indicated on the mammo graphic findings alone, a
ultrasound is done because if the lesion is identified on ultrasoun ,
A 1-cm, ir regular, spiculated mass is confi med on the spot com-
a core biopsy can be done easily and expeditiously using ultrasound
pression views. A small focus of pleomorphic calcifications is als
guidance.
noted in the tissue adjacent to the mass. In the absence of symptoms
suggesting an ongoing infection, or a histor y of surgery or trauma
G H
Figure 3.8. (Continued) Ultrasound images in the radial (RAD) (G) and antiradial (ARAD) (H) projections at the 3 o’clock position, 3 cm from the right
nipple.
localized specifical y to this area, papilloma, sclerosing adenosis,

Is this the correct location for the mammographic
mastitis, granular cell tumor (rare), extra-abdominal desmoid (rare),
finding? invasive ductal carcinoma not otherwise specifie , tubular carci-
What is your differential? noma, or invasive lobular carcinoma. Rarely, ductal carcinoma in situ
can present as a mass, asymmetrical density , or distor tion in the
A hypoechoic mass with ir regular, spiculated, and angular margins, absence of microcalcifications. G ven the imaging features of this
associated shadowing, and disruption of Cooper ligaments is imaged, lesion (i.e., a spiculated mass with adjacent calcifications), the ork-
corresponding to the area of mammo graphic concern. Although the ing diagnosis for this patient is an in vasive ductal carcinoma with
lesion projects belo w the le vel of the nipple on the mediolateral associated ductal carcinoma in situ.
oblique view, the lesion imaged on ultrasound cor responds to the BI-RADS® category 4: suspicious abnor mality, biopsy should
lesion seen mammographically (Fig. 3.8I–K). Differential considera- be considered.
tions include f at necrosis if the patient has had sur gery or trauma
I J
Figure 3.8. On the right mediolateral oblique (I) view, the lesion is “X” cm
below the posterior nipple line (PNL). On the craniocaudal (J) view, the
lesion is medial in location. On the frontal diag ram of the right breast (K),
a line is drawn “X” cm below the PNL so that, in combination with the loca-
tion of the lesion on the CC vie w, you can approximate the location of the
K lesion at the 3 o’clock position.
An ultrasound-guided biopsy is undertaken, and an invasive duc- raphy can be used to assess the pattern of lymphatic drainage before
tal carcinoma is repor ted on the cores. A 0.9-cm, grade I invasive surgery; this also provides information regarding the internal mam-
ductal carcinoma with associated cribriform-type ductal carcinoma mary lymph nodes. Alternatively, a gamma probe is used intraoper-
in situ is diagnosed on the lumpectomy specimen. Two excised sen- atively to identify the “hot spots” in the axillary tail without preop-
tinel lymph nodes are normal [pT1b, pN0(sn) (i), pMX; Stage I]. erative lymphoscintigraphy. It has been suggested b y many
researchers that optimal results are obtained when blue dye and iso-
tope are used in combination. In a review of the literature correlat-
What is the basic concept underlying sentinel lymph ing SLNB with ALND in more than 3,000 patients with breast can-
node biopsies? cer, Liberman reported technical success rate, sensiti vity, and
accuracy of 88%, 93%, and 97%, respectively, for SLNB.
Traditionally, most patients diagnosed with in vasive breast cancer The use of SLNB in patients with ductal carcinoma in situ
had axillary lymph node dissections (ALND) for staging and as (DCIS) remains controversial. It is probab ly indicated for w omen
part of the sur gical treatment of their breast cancer (i.e., local- with DCIS and kno wn microinvasion and for patients in w hom
regional control). More recentl y, sentinel l ymph node biopsy invasive disease is suspected preoperati vely based on the size or
(SLNB) has been suggested as an alternative to assess the status of imaging features of the DCIS. The alternative approach that can be
the axilla and is being used increasingly to replace ALND for most taken is to excise the DCIS and, if invasive disease is identified o
women diagnosed with breast cancer. It is postulated that the sen- the lumpectomy specimen, have the SLNB done as a second opera-
tinel lymph node(s) is the first node draining a tumo , and that the tive procedure.
histologic status of this lymph node accurately predict the status of
the regional (axilla) lymphatic basin.
Given some of the complications associated with ALND, sen- What is the prognostic significance of isolated tumor
tinel lymph node biopsies are no w used routinely at many institu- cells or micrometastatic disease described following
tions as an alternative to ALND for patients with clinically normal a sentinel lymph node biopsy?
axillary exams. Axillary lymph node dissections are under taken if
the sentinel lymph node(s) is not identifie , metastatic disease is The advent and now widespread use of sentinel lymph node biopsy
known to be present following fine needle aspiration (F A), or core has resulted in a more meticulous e valuation of e xcised lymph
biopsy, of ultrasound-detected, abnormal lymph nodes in the axilla, node(s). This includes serial sectioning of the entire lymph node (as
or when abnormal lymph nodes are suspected clinicall y. Axillary opposed to sample sections from multiple lymph nodes) and a more
lymph node dissection ma y also be perfor med in patients with focused histologic and immunohistochemical (IHC) e valuation of
metastatic disease in the sentinel l ymph node(s), to estab lish the the excised lymph node. Some of the consequences include the
number of axillary lymph nodes involved by tumor. observation of isolated tumor cells and micrometastatic disease.
The methods used to identify the sentinel l ymph node are still Consequently, the significance of these findings (e.g., isolat
evolving, undergoing investigation, and vary among institutions. In tumor cells and micrometastases) involving excised sentinel lymph
general, a radioisotope is used alone or in combination with a b lue nodes is not yet clear, and there is no consensus on their prognostic
dye (e.g., l ymphazurin blue) for l ymphatic mapping; these are significance. Currently, the use of IHC evaluation of sentinel lymph
injected in a peritumoral, intrader mal, periareolar, or intratumoral nodes is not encouraged; ho wever, it is done at man y institutions.
location. The volume used and the inter val between injection and The determination of micrometastatic disease should be based on
surgery vary. If a radioisotope is used, preoperative lymphoscintig- routine hematoxylin and eosin–stained histologic sections.
PATIENT 9
Figure 3.9. Diagnostic evaluation, 79-year-old patient presenting with a “lump” in the mid-axillary region inferior
to the left axilla. Craniocaudal (A) and mediolateral oblique (B) views.
C D
E
F
Figure 3.9. (Continued) Mediolateral oblique (C) view photographically coned, left breast. A spot tangential view of the palpable area could not be obtained.
Ultrasound images (D, E) of the palpable finding in the left breast. Ultrasound image (F) of tissue surrounding the palpable finding. atient is on coumadin.
How would you describe the findings? What diagnostic considerations would you entertain?
Based on the mammographic findings, what BI-RADS®
Scattered dystrophic and lar ge rodlike calcifications are presen assessment category would you assign, and what
bilaterally. A mixed-density (fat containing) mass is imaged on the would you do next?
left mediolateral ob lique view, superimposed on the left pectoral
muscle, corresponding to the area of clinical concer n. The trabecu- The main dif ferential considerations for a mix ed-density lesion
lar markings sur rounding the mass are more dense and numerous include lymph node, fibroadenolipoma (hama toma), fat necrosis, oil
compared to those in the corresponding area on the right. Given the cyst, galactocele, postoperative or posttraumatic fluid collection
far lateral and posterior location of the lesion, it is not imaged on the and abscess. Although malignant lesions may rarely entrap fat, fat-
craniocaudal view and a spot tangential view could not be obtained. containing lesions should be considered benign; consequentl y, no
malignant lesions are usually included in the differential for a mixed- there is no skin discoloration, there w as a large ecchymotic area at
density lesion. Prior studies in this patient are normal. Specifical y, no this site immediately following the trauma. The currently palpable
lymph node or fibroadenolipoma is seen in the upper outer quadran mass developed as the ecchymosis resolved.
of the left breast. A galactocele is not a consideration in a 79-year-old As hematomas e volve clinically, so do their imaging features.
patient. Primary considerations at this point include an abscess or a Acutely, there may be a water-density mass. As the hematoma ages,
hematoma (particularly because the patient is on coumadin), both of a mixed-density mass is often seen mammo graphically. This may
which also help explain the associated prominence of the trabecular resolve completely, or an oil c yst may develop eventually, as can
markings. Physical findings and additional histo y may be helpful in dystrophic calcifications. On ultrasoun , a complex cystic mass or
sorting through these possibilities. a solid mass with a hetero geneous echotexture that ma y include
On physical examination, there is a hard mass just inferior to the hyperechoic, hypoechoic, and cystic areas can be seen. Increased
left axilla at the mid-axillar y line; no associated skin changes or echogenicity (e.g., reflecting yperemia) and disruption of the nor-
discoloration are noted at this time. The mass is superficial, readi y mal tissue architecture is often found in the surrounding tissue.
mobile, and nontender. An oval, well-circumscribed mass with a BI-RADS® category 2: benign finding. ollow-up physical
heterogeneous echotexture is imaged on ultrasound at the site of the examination and ultrasound in 3 to 4 months is recommended for
palpable abnormality. Areas of posterior acoustic enhancement are this patient, to assure resolution. Note that the BI-RADS® assess-
associated with the cystic areas in the mass, and shado wing is noted ment categories should be considered independent of the recommen-
with the more solid components. The surrounding tissue is echogenic, dation. For this patient, the finding is benign, et a shor t-interval
consistent with hyperemia, there is disr uption of the nor mal tissue follow-up is recommended. F or patients in w hom I suspect an
architecture, and lymphatic channels or interstitial fluid collections inflammato y condition or posttraumatic/sur gical changes, I rec-
are seen as thin hypoechoic linear channels subcutaneously. In the ommend a 3- to 4-month follo w-up. Under these circumstances, a
absence of significant tende ness or er ythema, an abscess is rapid change (evolution) is expected in the findings. Six months i
unlikely. On questioning the patient at the time of the ultrasound,she the usual recommendation for other patients for w hom a shor t-
has not had any surgery to either breast, but she does describe ha v- interval follow-up is recommended (e.g., those with assessment
ing had trauma to this site se veral weeks before while being lifted category 3—probably benign lesion, such as a w ell-circumscribed
from her bed on a Ho yer lift. She states that although at this time mass in a patient with no prior studies).
PATIENT 10
A B
Figure 3.10. Diagnostic evaluation, 24-year-old patient presenting dur-

ing the third trimester of pre gnancy with a “lump” in the left breast.
C Ultrasound images, radial (RAD) (A, B) and antiradial (ARAD) (C) projec-
tions of the palpable (PALP) mass, laterally in the left breast.
What is your approach to adolescent, pregnant or How would you describe the ultrasound findings, and
lactating women, or those under the age of 30 years what is the most likely diagnosis?
who present with breast-related symptoms?
Under what circumstances would you do a On physical examination a discrete, readily mobile, nontender mass is
mammogram in this patient population? palpated at the 9 o’clock position, 1 cm from the left nipple. This cor-
responds to the site of concer n to the patient. A well-circumscribed,
Physical examination and an ultrasound are the initial tools used 3.7-cm, oval mass with inter nal septations and some posterior
in evaluating adolescent, pregnant or lactating w omen, or those acoustic enhancement is imaged corresponding to the palpable mass.
under the age of 30 years who present with breast-related symp- Given the clinical and imaging findings, a lactational adenoma is th
toms. If breast cancer is suspected after the initial e valuation, or most likely diagnosis. An ultrasound-guided core biopsy can be done
diagnosed following a core biopsy, a complete bilateral mammo- to confi m this impression; clinical and sonographic follow-up is also
gram is done. discussed with the patient as an acceptable alternative.
mitotic activity. Fibrotic bands and areas of inf arction can be seen
What is the typical clinical presentation and course for
in a small number of the lesions.
lactational adenomas, and what are the ultrasound
features associated with these lesions?
Pregnancy and breast cancer
Although they are ter med lactational adenomas, man y of these
lesions present during the third trimester of pre gnancy as a well- Pregnancy-associated breast carcinoma (PABC) is defined as breas
circumscribed, mobile mass. Rarely, when these grow rapidly dur- cancer that is diagnosed during pregnancy or in the year following
ing the second and third trimesters of pre gnancy, they outstrip delivery. It is estimated to af fect between 1 in 1,500 to 1 in 3,000
their vascular supply, resulting in areas of inf arction so that pregnant women, and some suggest that this incidence will increase
patients present acutel y, describing a rapidl y enlarging, tender as women delay their child-bearing y ears. The tumors that occur
mass. In most patients, lactational adenomas decrease in size sig- during pregnancy are similar to those diagnosed in nonpre gnant
nificant y or resolv e completely after deli very or follo wing the patients. Although some patients have advanced disease at the time
cessation of lactation. They may recur with subsequent pre gnan- of diagnosis, this is attributed to delays in seeking medical attention
cies. Patients with these lesions can be managed conser vatively or masses being followed clinically rather than any inherent aggres-
unless they are anxious or symptomatic (e.g., tenderness) relief is sive biologic attribute of the tumors developing during gestation or
indicated. to any pregnancy-related hormonal stimulation of the tumors.
The ultrasound features of these lesions suggest a benign etiol- Diagnosis and staging, ter mination of pregnancy, timing of local
ogy in many patients and include o val shape, well-circumscribed and systemic adjuvant therapy and the potential ef fects of this ther-
margins that may have smooth lobulations, homo genous internal apy to the fetus are some of the concer ns facing patients diagnosed
echotexture, and posterior acoustic enhancement. F ibrous bands during pregnancy and the interdisciplinary team of physicians taking
traversing the lesion and cystic changes may also be noted on ultra- care of the patient. If treatment is modifie , consideration has to be
sound. However, in some patients, the lesions may demonstrate fea- given to the potential adverse effects to the mother. Even small doses
tures more suggesti ve of malignanc y, including ir regular, angu- of radiation during the first trimester of pr gnancy are associated
lated, and ill-defined ma gins and shadowing, requiring biopsy. with significant ad erse effects to the developing fetus, such that ter-
mination of pregnancy is a serious consideration if radiation therapy
is deemed critical during the first trimeste . Given the potential
What histologic features characterize lactational adverse effect of radiation to the fetus, some adv ocate mastectomy
adenomas? for patients diagnosed with breast cancer during the first t o
trimesters of pregnancy. When patients are diagnosed later in pre g-
It is unclear whether these tumors arise de novo during pregnancy, nancy, they may be treated conservatively with surgery and radiation
or whether they reflect the presence of a pre- xisting fibroadenom therapy can be deferred until after delivery. Alternatively, patients can
or tubular adenoma, stimulated by the hormonal changes that occur be induced after 34 weeks with small risk to the fetus, and radiation
during pregnancy. Histologically, the features of lactational adeno- therapy can then be given following the delivery. Unlike the effects of
mas vary, depending on the stage of the pregnancy at the time of the radiation on a developing fetus, less is known concerning the effects
diagnosis. Tubules are distended with secretor y material and the of chemotherapy on pregnancy and the developing fetus; some sug-
lining epithelial cells sho w cytoplasmic vacuoles and v ariable gest it can be used safely after the first trimeste .
PATIENT 11
A B
C D
Figure 3.11. Diagnostic evaluation, 50-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views
photographically coned to the area of concern in the left breast. Spot compression (C) view and ultrasound image (D) of the palpable finding. Metallic BB use
by the technologist to mark the area of concern to the patient.
larly if there is associated tenderness, erythema, and increased tem-

How would you describe the finding?
perature localized to the palpable site; or a galactocele if there is a
What are your differential considerations, and what is history of pregnancy within the last several years. A papilloma, focal
your recommendation? fibrosis, pseudoangiomatous stromal hyperplasia, phyllodes tumor,
sclerosing adenosis, g ranular cell tumor , or an e xtra-abdominal
A round, spiculated, 1.5-cm mass is imaged in the upper outer desmoid (fibromatosis) are additional benign considerations
quadrant of the left breast, cor responding to the site of concer n to Invasive ductal carcinoma not otherwise specifie , medullary, muci-
the patient. A solid mass with associated shado wing is seen on nous, and papillary carcinomas, lymphoma, or metastatic disease are
ultrasound at the 1 o’clock position, 10 cm from the left nipple. all malignant considerations. A biopsy is indicated.
Differential considerations for w hich history and physical exami- BI-RADS® category 4: suspicious abnor mality, biopsy should
nation may be helpful include f at necrosis if there is a histor y of be considered.
recent trauma or surgery localized to this site; an abscess, par ticu-
A granular cell tumor is repor ted histologically, and a wide sur- as spiculated masses. A solid mass with shado wing is the most
gical excision is done. common ultrasound appearance of these lesions. Although reports
in the literature are scant, it may be that benign granular cell tumors
lack the features of malignanc y on dynamic sequences with mag-
What are the clinical manifestations of granular cell netic resonance imaging (e.g., no significant contrast upta e).
tumors in the breast, and what is the treatment of
choice?
What are some of the histologic features associated
Granular cell tumors can occur anywhere in the body but have some with granular cell tumors in the breast?
predilection for the head and neck, including the oral ca vity.
Approximately 5% of these tumors occur in the breast, including in Although the lesions appear well circumscribed grossly, an infiltra
male patients. Wide excision is the treatment of choice because less tive pattern is commonly noted histologically. Nests, or solid sheets,
than 1% of these lesions are malignant, but local recur rences have of cells with eosinophilic granules in abundant cytoplasm are char-
been reported following incomplete e xcision. Clinically, patients acteristic of this tumor . These cells, in contrast to those seen in
describe a fi m, hard, nontender mass. Superficial or subareola apocrine carcinomas, w hich they can resemb le, contain gl ycogen
lesions may cause skin retraction or nipple in version, respectively. and have a positive immunoreaction for S-100 protein.These tumors
Rarely, patients with one g ranular cell tumor of the breast can be may also be positive for carcinoembryonic antigen (CEA), however,
found to have multiple or bilateral breast lesions or g ranular cell they are ne gative for estro gen and pro gesterone receptors. Gi ven
tumors in locations outside the breast. The age of presentation is their positive immunoreaction for S-100 protein, these tumors are
variable, ranging from 17 to 75 years. thought to have a neural origin (possibly Schwann cells).
What are the described imaging findings associated

with granular cell tumors?
Mammographically, granular cell tumors ma y be round masses

with well-circumscribed to spiculated margins, or they can present
PATIENT 12
Figure 3.12. Screening study, 78-year-old woman.

Craniocaudal (A) and mediolateral ob lique (B) views.
Comparison mammogram from 2 years previously (not
B shown) is nor mal. The patient is not on hor mone
replacement therapy.
compression views for confi mation and marginal analysis, correl-

What is the primary observation and, specifically, what
ative physical examination and an ultrasound are indicated.
would you do next?
A mass is present in the left breast.

BI-RADS® category 0: additional imaging e valuation is indi-
cated. The patient is called back for additional e valuation. Spot
Figure 3.12. (Continued) Spot compression views, craniocaudal (C) and mediolateral oblique (D) projec-
tions, left breast mass.
occurrence in older , postmenopausal w omen. Considerations for

How would you describe the mass, and what is your
malignancy include invasive ductal carcinoma not otherwise speci-
differential at this point? fie , mucinous carcinoma, papillar y carcinoma, l ymphoma, or
What is the next step? metastatic disease. A fibroadenoma or focal fibrosis is unl ely to
develop in a 78-year-old woman, particularly if she is not on hor-
A round 1.5-cm mass with par tially indistinct margins is imaged mone replacement therap y. Although they are more common in
mammographically. Also noted are benign-type calcifications in th older women, invasive lobular carcinomas do not usually present as
adjacent tissue. Differential considerations for a benign water-den- a round mass.
sity mass de veloping in a 78-y ear-old woman are limited but Next, an ultrasound study is done to evaluate the internal charac-
include cyst, focal fibrosis, papilloma, abscess, and p yllodes teristics of this mass. Also, if it is seen on ultrasound and it is solid,
tumor. Although cysts more commonl y develop in the peri- a core biopsy can be done. In planning the ultrasound, at what clock
menopausal years (heralding the be ginning of menopausal signs, position would you expect to find this mass
with symptoms in some women), there is a second, smaller peak of
E Figure 3.12. (Continued) Ultrasound image, radial (RAD) (E) projection

correlating to the area of mammographic concern, left breast.
How would you describe the ultrasound findings? in two sentinel lymph nodes [pT1c, pN0(sn) (i), pMX; Stage I]. By
definition, pure mucinous carcinomas are rade I lesions.
What do you think is the most likely diagnosis, and
what is your recommendation?
What are the clinical and imaging features associated
A nearly isoechoic, round mass with par tially circumscribed and with mucinous carcinomas?
indistinct margins is imaged at the 1 o’clock position, 4 cm from the
left nipple. There is some posterior acoustic enhancement. The mass The imaging features of mucinous carcinomas are w ell demon-
is not palpable, there is no associated skin discoloration, and no ten- strated in this patient. Characteristicall y, they develop in older
derness is elicited as gentle pressure is applied directly over the mass. women as round water-density masses with a range of well circum-
The ultrasound e xcludes the possibility of a c yst. An abscess is scribed to indistinct mar gins; some ma y demonstrate macro- or
unlikely in the absence of an y associated skin change or tender ness, microlobulation. On ultrasound, the lesions are often iso- to slightly
and the ultrasound features are not suggesti ve of an abscess. A solid hyperechoic with associated posterior acoustic enhancement;
mass developing in a 78-year-old woman requires biopsy; given the rarely, a comple x cystic mass ma y be seen on ultrasound.
patient’s age, and the imaging features of this lesion (i.e., round, 1.5- Depending on the amount of mucin present, a bright T2-weighted
cm mass, nearly isoechoic with posterior acoustic enhancement), a signal can be seen on magnetic resonance imaging. Enhancement
mucinous carcinoma is a primary consideration. When doing the core following contrast is variable and may be limited to the edge of the
biopsy, evaluate the cores carefull y: Cores from mucinous carcino- lesion (irregular rim enhancement).
mas have a distinctive gelatinous (Fig. 3.12F, G), almost clear appear-
ance (i.e., not stif f, solid white), and tiny air droplets will de velop
along the edge of the cores when they are placed in 10% formalin. What are the histologic findings associated with
BI-RADS® category 4: suspicious abnor mality, biopsy should mucinous carcinomas?
be considered. An ultrasound guided core biopsy is done.
On MR, a small component of the mass centrally demonstrates a Mucinous carcinomas, also called colloid carcinomas, are a sub-
high signal on T2-weighted images (F ig. 3.12H). On the T1- type of invasive ductal carcinoma characterized b y aggregates of
weighted dynamic sequence (Fig. 3.12I, K), there is rapid w ash-in low-grade malignant cells floating in pools of mucin ( ig. 3.12L,
and wash-out of contrast, with rim enhancement. No additional M). The mucin-to-cell ratio v aries from lesion to lesion, and this
lesions are identified in either breast may explain some of the imaging v ariability seen with these
An invasive mammary carcinoma with mucinous features is lesions. Associated ductal carcinoma in situ may be seen in as many
reported following the ultrasound-guided core biopsy. A 1.5-cm muci- as 75% of patients, usually at the periphery of the lesion. These are
nous carcinoma is diagnosed on the lumpectom y specimen, with no usually diploid tumors with estro gen and progesterone receptors.
associated ductal carcinoma in situ. No metastatic disease is identifie Mucinous carcinomas represent 1% to 2% of all breast cancers.
F G
Figure 3.12. (Continued) Core samples (F, G) demonstrating the typical appearance of a mucinous lesion. The core is gelatinous, with a glassy, glistening
appearance. This is in contrast with the stiff, usually white cores obtained through nonmucinous, malignant lesions.
H I
J K
L M
Figure 3.12. (Continued) Magnetic resonance imaging, T2-weighted sagittal image (H), right breast. T1-weighted sagittal image (I), right breast, precon-
trast. T1-weighted sagittal image (J), right breast, 1 minute following an intravenous bolus of contrast, same tabletop position as shown in (I). Subtraction image
(K), same tabletop position as (I).Mucinous carcinoma in two different patients (L, M). Clusters of low-grade malignant cells floating in pools of mucin sepa
rated by fibrous septa. The cellularity of the aggregates is variable within and among lesions.
PATIENT 13
B
Figure 3.13. Diagnostic evaluation, 52-year-old patient presenting with a “lump” in the upper outer quadrant of the left
breast (metallic BB marking “lump”). Craniocaudal (A), mediolateral oblique (B) views.
C
Figure 3.13. (Continued) Right craniocaudal and left craniocaudal view exaggerated laterally (C) views. Metallic BB is
used by the technologist to mark the area of clinical concern.
tubular adenoma), phyllodes tumor, focal fibrosis, pseudoangioma

What is your differential for the mammographic
tous stromal hyperplasia (PASH), papilloma, abscess, postoperative/
finding, and what would you do next? posttraumatic fluid collection, i vasive ductal carcinoma not other-
wise specified (NOS), mucinous carcinoma, medulla y carcinoma,
An oval, well-circumscribed, 2.5-cm mass is imaged on the medio-
papillary carcinoma, apocrine carcinoma, adenoid c ystic carci-
lateral oblique view, corresponding to the palpab le abnormality.
noma, lymphoma, and metastatic carcinoma. A galactocele is
This is partially imaged on the routine left craniocaudal vie w but
unlikely in a 52-y ear-old woman. Physical examination and an
imaged in its entirety on the craniocaudal vie w exaggerated later-
ultrasound are done next to further characterize the mass.
ally. Diagnostic considerations for an oval-round mass in a 52-year-
old woman include c yst, fibroadenoma (compl x fibroadenoma
D E
Figure 3.13. (Continued) Ultrasound images in radial (D) and antiradial (E) projections corresponding to the palpable mass in the upper outer quadrant of
the left breast.
On MR, variable signal intensities are noted on the T2-weighted

How would you describe the ultrasound findings in this
images (Fig. 3.13F, G). Following contrast administration, rapid
patient? nonuniform enhancement of the mass is noted on the T1-weighted
What are your primary considerations now, and what is images (Fig. 3.13 H, I).
your recommendation for this patient?
On physical examination, a discrete, readily mobile, hard mass is pal- What are the imaging features that may distinguish
pated in the upper outer quadrant of the left breast.There is no skin dis- central from peripheral papillary carcinomas?
coloration. On ultrasound, a well-circumscribed complex cystic mass
with posterior acoustic enhancement is imaged at the 1- to 2-o’clock As with papillomas, papillary carcinomas are considered either cen-
position in the left breast. No histor y of surgery or trauma is elicited tral (i.e., subareolar) or peripheral. P atients with central papillar y
from the patient, and there is no associated tender ness when this area carcinomas usually present with a w ell-circumscribed mass in the
is palpated. The ultrasound eliminates the possibility of a simple cyst. subareolar area. The mass may be large enough to cause nipple dis-
With no history of surgery or trauma, this is unlikely to represent post- placement and overlying skin stretching. Some patients ma y have
operative or posttraumatic fluid collection an , in the absence of sig- associated nipple discharge. A complex cystic mass is commonl y
nificant tenderness or erythema, it is unlikely to represent an abscess. seen on ultrasound. Bloody fluid is often obtained on aspiration
Given the age of the patient, the size of the lesion, and its comple x Patients with peripheral papillar y carcinomas can present with one
appearance on ultrasound, mucinous carcinoma is unlik ely. An inva- or multiple masses with w ell-circumscribed to ill-defined but no
sive ductal carcinoma NOS with necrosis (gi ven the complex cystic usually spiculated mar gins. Solid, hypoechoic or comple x cystic
appearance sonographically) or a papillary lesion is the primar y con- masses are imaged on ultrasound. P apillary carcinomas represent
sideration at the time of the ultrasound-guided core biopsy. approximately 1% to 2% of all breast cancers and are characterized
BI-RADS® category 4: suspicious abnor mality, biopsy should by in-situ and invasive variants.
be considered. An invasive papillary carcinoma is diagnosed fol-
lowing the ultrasound-guided needle biopsy.
F G
H I
Figure 3.13. Magnetic resonance imaging, T2-weighted sagittal images (F, G) at two different tabletop positions. T1-weighted sagittal image (H), left breast,
precontrast. T1-weighted sagittal image (I), left breast, at the same tabletop position as (H), 1 minute following bolus intravenous administration of contrast.
PATIENT 14
Figure 3.14. Diagnostic evaluation, 51-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A)
and mediolateral oblique (B) views with a metallic BB at the site of concern to the patient.
Figure 3.14. (Continued) Mediolateral oblique

D (C), photographically coned view, inferiorly. Spot
tangential (D) view, palpable mass, left breast.
collection, invasive ductal carcinoma not otherwise specifie ,

How would you describe the finding, and what is your
mucinous carcinoma, medullar y carcinoma, papillar y carcinoma,
differential? lymphoma, and metastatic disease. Given its proximity to the skin
What will you ask the patient, and what will you be on the spot tangential vie w, an inflamed sebaceous yst is also
looking for when you examine her and do the ultrasound? included in the differential. A galactocele is unlikely in a 51-year-
old woman unless there has been a pregnancy with lactation within
A mass with indistinct and ill-defined ma gins is imaged, corre- the last several preceding years. The patient should be asked ques-
sponding to the area of concer n to the patient. Prominence of the tions relative to associated symptoms (e.g., “heat” o verlying the
surrounding trabecular mar gins is also noted. A well-circum- area, tenderness, general malaise, or recent trauma to this site).
scribed, dense lymph node is present inferiorly in the left axilla. It Before starting the ultrasound , examine the skin for er ythema,
retains a fatty hilar region, and comparison with prior studies would ecchymosis, or a prominent skin pore possib ly associated with a
be helpful in assessing an y change in size and o verall density. On sebaceous cyst. Compare the skin temperature o verlying this area
the mammographic findings alone, di ferential considerations with the corresponding area on the contralateral breast.
include inflamed yst, abscess, posttraumatic/postoperati ve flui
E F
Figure 3.14. Ultrasound images in transverse (TRS) (E) and longitudinal (LON) (F) projections at the site of concern to the patient, left breast, medially.
and imaging is not usually indicated. It is impor tant to recognize,

however, that nonlactating w omen of all ages can present with
What is your working diagnosis, and what would you mastitis or a breast abscess. For women who are not lactating, con-
recommend? sider two groups of patients with different presentations and clini-
cal courses: those with peripheral mastitis or abscess and those
On physical examination, there is a small patch of er ythema over- with subareolar mastitis or abscess. Peripheral mastitis or abscess
lying the mass, and this area is warmer than the comparable area on is seen in women of all ages and, although some patients may have
the contralateral breast. The mass is not associated with skin an underlying condition such as diabetes that may predispose them
because it can be moved independently of the skin (i.e., it is not a to the infection, most are otherwise health y individuals. Patients
sebaceous cyst). Some tender ness is elicited on deep palpation. usually respond well, with complete resolution of symptoms and
There is no history of trauma or surgery. On ultrasound, the tissue findings, following one or two courses of antibiotics. Recur rence
is hyperechoic with associated ir regular fluid collections at the following treatment is uncommon in these patients. In contrast,
o’clock position, 6 cm from the left nipple. Normal tissue architec- patients with subareolar mastitis or abscess are usuall y young (in
ture is disr upted. Given the clinical, mammo graphic, and ultra- their 30s) and hea vy smokers. Acutely, some of these patients
sound findings, an abscess with an associated ongoing inflamm develop periareolar fistulas (Zuska s disease) that drain pur ulent
tory process is the primary consideration. The patient is prescribed material. Patients with subareolar abscesses can be difficult to treat
a course of antibiotics, with a follow-up ultrasound scheduled after effectively and recurrences following treatment, requiring surgical
completion of the antibiotic course. incision and drainage, are common, as is the development of con-
The need for an aspiration for fluid valuation (i.e., g ram stain tralateral subareolar abscess.
and culture) and to remove as much of the infected fluid as possi le BI-RADS® category 2: benign finding. A follow-up ultrasound
is something to consider in women in whom you suspect an ongoing is scheduled in 3 w eeks to confi m complete resolution of symp-
inflammato y process. Acutely, in some of these patients, aspirations toms and findings. If symptoms persist and there are residual fin
can be quite painful and often yield little fluid ( ven with an 18G or ings on the ultrasound, a second course of antibiotics is prescribed
16G needle). Nevertheless, depending on the size of individual flui for some patients. Alternatively, if a larger fluid collection is identi
collections, an aspiration can be done; presumab ly, removing as fied sonographically at the time of the follo w-up ultrasound, an
much of the fluid as possi le will improve the effectiveness of the aspiration may be done.
antibiotics. In this patient, given the relatively small size of the mass
and the presence of small fluid locules on ultrasound (as opposed t
one single fluid collection), aspiration is not done
With respect to inflammatory lesions in the breast,

what are the two groups of nonlactating patients to
consider and how do their clinical courses differ?
Traditionally, mastitis and abscesses are associated with lactating

patients. Obstetricians manage this g roup of patients clinicall y,
PATIENT 15
Figure 3.15. Diagnostic evaluation, 59-year-old woman presenting with a “lump” in the right breast. Craniocaudal (A)
and mediolateral oblique (B) views; metallic BB placed at the site of the palpable finding.
D
Figure 3.15. (Continued) Spot compression views, right breast, craniocaudal (C) and mediolateral oblique (D) projections.
E Figure 3.15. (Continued) Ultrasound image (E) of palpable finding, 9 o’cloc

position, zone 2/3 (Z2/3), right breast.
biopsy (this information is also factored in when considering inva-

sive lobular carcinoma as the likely diagnosis).
differential? Following ultrasound-guided core biopsies, invasive lobular car-
cinomas are diagnosed bilaterall y. Multicentric (5.5-cm and 3-cm
An irregular mass with spiculation, associated distor tion, and scat-
foci) invasive lobular carcinoma with associated l ymphovascular
tered punctate calcifications is present in the right breast, co respon-
space involvement is diagnosed follo wing a right simple mastec-
ding to the area of clinical concern. It is more prominent on the cran-
tomy. Metastatic disease is identified in one xcised right axillary
iocaudal view. On physical examination, no definite mass is palpated
lymph node [pT3, pN1, pMX; Stage IIIA]. A 4.5-cm invasive lobu-
however, the tissue at the 9 o’clock position, 5 to 6 cm from the right
lar carcinoma with associated lymphovascular space involvement is
nipple, is hard and thickened. On ultrasound, an irregular mass with
diagnosed in the left breast follo wing a simple mastectom y.
an echogenic rim and significant shad wing measuring at least 4 cm
Metastatic disease is diagnosed in 8 of 14 e xcised left axillar y
is imaged, corresponding to the area of clinical concer n. Given the
lymph nodes [pT2, pN2, pMX; Stage IIIA].
lack of a discrete mass on ph ysical examination, a more prominent
appearance on the craniocaudal view, and the amount of shado wing
seen on ultrasound, an invasive lobular carcinoma is a more lik ely What are the clinical, mammographic, and sonographic
diagnosis; however, invasive ductal carcinoma can present with sim- findings associated with invasive lobular carcinoma?
ilar findings. ossible benign considerations are limited but include
an inflammato y process or diabetic fibrous mastopat y if the patient Invasive lobular carcinoma is the second most common type of
has a history of long-standing, insulin-dependent diabetes. breast cancer, with a reported incidence of 5% to 15%. The inci-
A biopsy is indicated. In planning for the biopsy, consider needle dence of this tumor type varies with patient age: It is uncommon
placement carefully. In my experience, these types of lesions with in premenopausal w omen and increases in frequenc y with
significant shadowing can be hard and often yield little or no tissue advancing age. Multifocality and bilaterality (synchronous or
on one or more of the passes. Sometimes the inner por tion of the metachronous) should be considered in patients diagnosed with
needle advances into the mass but the outer sheath does not follow invasive lobular carcinoma. Clinicall y, a discrete mass ma y be
because it cannot cut through the tissue adequatel y. In tar geting palpated; however, it is more common to palpate an area of thick-
these lesions, I aim for the edges of the lesion as opposed to trying ening (described b y some as “induration”), w hich in some
to advance the needle into the area of shadowing and, depending on patients can be subtle.
the appearance of the tissue obtained , I will mak e extra passes as A spiculated mass is the most common mammo graphic findin
needed to obtain one or two solid tissue cores. in women with invasive lobular carcinoma, occur ring in close to
40% of patients. P arenchymal asymmetry and distor tion are the
next most common mammo graphic findings. These changes may
So, are we done with this patient? Do you have any
be more apparent in one projection, commonl y the craniocaudal
additional observations? How about the left breast? view. Diffuse changes include a pro gressive shrinkage of the
involved breast or, alternatively, diffuse enlargement and reduced
Remember, when presented with ob vious clinical and mammo-
compressibility of the involved breast may be seen. Invasive lobu-
graphic findings, focus way from them and evaluate the remainder
lar carcinoma rarely presents as a round or o val mass. Lik ewise,
of the mammogram. Did you notice the irregular mass with associ-
when an invasive lobular carcinoma is diagnosed follo wing biop-
ated spiculation and distor tion in the left breast (comparab le loca-
sies done for microcalcifications, the calcifications are usua y not
tion to that on the right)? The patient has bilateral lesions, requiring
found in association with the invasive lesion. The calcifications ar extent of disease is often underestimated clinicall y, mammo-
found in benign changes such as fibro ystic changes, fibroade graphically, and sonographically. In our own patients, metastatic
noma, and sclerosing adenosis, and the invasive lobular carcinoma disease to the axilla is seen in as man y as 60% of patients at the
is an incidental finding time of presentation.
Solid masses with irregular, spiculated, and angular margins are
seen on ultrasound. Subtle distor tion may be the onl y finding o
ultrasound. In some lesions (such as the one presented here), sig- What are the distinguishing histologic features of these
nificant shadowing is seen associated with the lesion. In our experi- lesions?
ence, some of the most striking shado wing seen is associated with
invasive lobular carcinomas. Histologically, small monomor phic cells infiltrating the stroma i
single files characterize these lesions. The cells infiltrate the tissu
insidiously, invoking little or no desmoplastic reaction (this lik ely
How accurately does mammography predict tumor reflects the subtle imaging changes associated with some of these
extent in patients with invasive lobular carcinoma? lesions). In a significant number of patients, lobular neoplasia (i.e.
lobular carcinoma in situ), although not considered as a precursor
Having described the imaging presentation of in vasive lobular or premalignant lesion, is seen in the tissue sur rounding invasive
carcinoma, it is important to emphasize that invasive lobular car- lobular carcinoma. Invasive lobular carcinomas often express estro-
cinoma can be subtle clinicall y, mammographically, sonographi- gen and progesterone receptors; rarely, the HER-2/neu oncoprotein
cally, and pathologically (I refer to it as the “sleaze disease”). The is expressed.
PATIENT 16
B
Figure 3.16. Diagnostic evaluation, 53-year-old patient presenting with a “lump” in the left breast. Craniocaudal
(A) and mediolateral oblique (B) views, metallic BB at site of “lump,” left craniocaudal view.
C D
Figure 3.16. (Continued) Spot tangential (C) view, left breast mass. Axillary (D) view, left axilla.
F
E
Figure 3.16. Ultrasound images in radial (RAD) (E) and antiradial

G (ARAD) (F) projections of the mass in the left breast. Ultrasound image(G)
of the mass in the left axilla.
consideration. Physical examination and an ultrasound are indi-

cated.
differential?
A round 1.5-cm mass with par tially circumscribed and indistinct How would you describe the findings?
margins is imaged in the left breast, cor responding to the area of Do you think this could be a cyst?
concern to the patient. An additional mass measuring at least 3 cm
is partially imaged in the left axilla. Given this constellation of find On physical examination, a hard mass is palpated at the 2 o’clock
ings, the differential is limited. Malignant possibilities include an position, 7 cm from the left nipple; a hard , fi ed mass is also pal-
invasive ductal carcinoma not otherwise specifie , with metastatic pated in the left axilla. No skin changes are noted, and no tenderness
disease to the axilla. Gi ven the mar gins and shape of the breast is elicited on palpation. A round, well-circumscribed, markedly
mass and the presence of axillar y adenopathy, this is lik ely to be hypoechoic mass with some posterior acoustic enhancement is
poorly differentiated. In premenopausal women with a round mass, imaged corresponding to the palpable finding in the breast, and a 4
medullary carcinoma is the primary subtype of invasive ductal car- cm, well-circumscribed, markedly hypoechoic (nearly anechoic)
cinoma to consider. Papillary and mucinous carcinomas also pre- mass is imaged in the left axilla. Although you might be tempted to
sent as round masses, but the y are more common in older , post- say that the mass in the axilla could be a cyst, it is important to rec-
menopausal women. Alternatively, this could represent lymphoma. ognize that abnormal, enlarged axillary lymph nodes can be nearly
An inflammato y process with abscess formation in the breast and anechoic in some patients.
reactive adenopathy in the axilla is a possib le benign diagnostic
spiculated. On ultrasound, they are moderately to markedly hypo-

echoic (they may simulate a cyst) and may demonstrate some poste-
rior acoustic enhancement. Because these tumors may have areas of
A malignant process has to be the leading consideration in this patient,
necrosis, you may obtain bloody material if you attempt an aspira-
so biopsies of the left breast and axillary masses are indicated.
tion; however, a residual solid component will remain, so a core
BI-RADS® category 5: highl y suggestive of malignanc y—
biopsy can be also be done.
appropriate action should be taken.
Appropriate action is tak en, and a medullar y carcinoma with
metastatic disease to the left axilla is diagnosed follo wing core What histologic findings are described for medullary
biopsies of the breast and axillar y masses. The patient is treated carcinoma?
with neoadjuvant therapy.
These tumors are described as having nests of large, high-nuclear-
What are the clinical and imaging findings associated grade epithelial cells for ming a sync ytial pattern and lacking a
significant amount of sur rounding stroma. The nuclei are pleo-
with medullary carcinoma?
morphic, and a high number of mitotic figures are present. The
tumors are sur rounded by a significant infiltrate of ymphocytes
Medullary carcinomas are a described subtype of in vasive ductal
and plasma cells. Ductal carcinoma in situ is not usually an asso-
carcinoma. When strict histologic criteria are used to classify these
ciated finding. Given the locall y aggressive nature of these
lesions, they represent 2% of all breast cancers. Clinicall y, they
lesions, areas of necrotic tumor ma y be present histolo gically.
present most commonly as a palpable mass that is often described
Presumably, the v ascular supply is outstripped b y the rapid
by the patient as developing rapidly. Mammographically, these are
growth of the tumor. Many of these tumors are estrogen and pro-
commonly round or oval masses with margins that can range from
gesterone receptor negative.
well circumscribed to ill-defined; h wever, they are not usuall y
PATIENT 17
A B
Figure 3.17. Diagnostic evaluation, 51-year-old patient presenting with a “lump” and thick ening of the left breast. Craniocaudal (A) and mediolateral
oblique (B) views with a metallic BB (arrow on CC view) used at the site of concern to the patient. Technical factors used for the exposures are as follows:
Factor RTCC LTCC RTMLO LTMLO

kV 26 31 26 27
mAs 296 293 269 439
Comp (mm) 63 76 60 68
matory changes (e.g., mastitis), trauma, ipsilateral axillar y

What do you think, and how would you describe the
adenopathy with lymphatic obstruction, dialysis shunt in the ipsi-
findings? lateral arm with fluid verload, invasive ductal carcinoma not oth-
erwise specifie , inflammato y carcinoma, invasive lobular carci-
The overall density of the left breast is increased and the breast
noma, or l ymphoma. Invasive lobular carcinoma can lead to
appears larger than the right. As evidenced by the millimeters of com-
increases in breast density and size or a decrease in breast size (the
pression used, the left breast is less compressible than the right. These
shrinking breast). Differential considerations for usuall y bilateral,
observations are confi med and suppor ted by the technical f actors
although sometimes unilateral, dif fuse changes include hor mone
used for adequate exposures. Although the kilovoltage used for the left
replacement therapy (e.g., estro gen), weight changes, congesti ve
mediolateral oblique (MLO) view is increased b y one compared to
heart failure, renal f ailure with fluid verload, and superior v ena
that used for the right breast, the resulting milliamperage is much
cava syndrome. Additional rare benign causes include g ranuloma-
higher on the left MLO . In comparison, w hen the kilo voltage is
tous mastitis, coumadin necrosis, ar teritis, and autoimmune disor-
increased to 31 kV for the left craniocaudal (CC) vie w, the resulting
ders (e.g., scleroderma). Obtaining a thorough histor y, examining
milliamperage is comparable to that noted for the CC and MLO views
the patient, and doing an ultrasound are often helpful in sor ting
of the right breast. Also noted are slightl y more prominent axillar y
lymph nodes in the left axilla compared to those in the right axilla.
What diagnostic possibilities are you considering at

this point?
What would you recommend?
Differential considerations for usuall y unilateral, although rarel y

bilateral, diffuse changes include radiation therap y effect, inflam
C D
Figure 3.17. Ultrasound images, radial (RAD) (C) and antiradial (ARAD) (D) projections, left breast laterally.
including warmth, heaviness, thickening, skin changes consistent

with edema ( peau d’orange) and redness of the breast. Although
there may be some tenderness, this is not usually a significant com
An irregular area of h ypoechogenicity, with associated areas of
ponent. Axillary adenopathy is present in 50% of patients with
enhancement and shadowing, is imaged at the 3:30 o’clock position
inflammato y carcinoma at the time of presentation. The diagnosis
4 cm from the left nipple. Some tender ness is elicited during the
of inflammato y carcinoma can sometimes be dela yed as patients
ultrasound study, but there is no erythema, increased warmth, or peau
are treated repeatedly with antibiotics. If symptoms do not resolve,
d’orange change. No other relevant clinical history is elicited (no his-
or worsen, on antibiotics, the diagnosis of an inflammato y carci-
tory of trauma, radiation therapy, or other known medical problems).
noma needs to be pursued aggressively. A skin biopsy is often done
The clinical and imaging findings do not pr vide a definite benig
to establish the diagnosis. However, if focal findings are identifi
etiology; rather they are of concern for a possible malignancy.
on ultrasound, an ultrasound-guided biopsy can also be helpful in
BI-RADS® category 4: suspicious abnormality—biopsy should
establishing the diagnosis. Because adenopathy reflecting metasta
be considered.
tic disease is common in women with inflammato y carcinoma, the
An ultrasound-guided core biopsy is done. A severe mastitis with
axilla should be scanned , and either a fine-needle aspiration or
features suggestive of abscess for mation is diagnosed on the core
core biopsy can be done if a potentiall y abnormal lymph node is
biopsy. Surgical incision and drainage is under taken following
identified
incomplete resolution of symptoms and findings after t o courses of
In patients with inflammato y carcinoma, the compressibility of
antibiotics. No malignancy is diagnosed on e xcised tissue taken at
the breast is significant y decreased, the density of the parenchyma
the time of the sur gical drainage, and the patient had an uncompli-
is increased, and associated skin thickening leads to significant dif
cated post-operative course with complete resolution of symptoms.
ficulties in obtaining an adequate e xposure mammographically
(two layers of thickened skin now need to be penetrated for ade-
What diagnosis has to be pursued aggressively in quate exposure of the parenchyma). On ultrasound, skin thickening,
patients with this type of presentation? disruption of the normal tissue architecture, increased echogenicity
of the tissue (consistent with hyperemia), and dilated subcutaneous
Given the clinical and mammographic presentation of this patient, lymphatic vessels can be seen. In a small number of women, one or
inflammato y carcinoma is the main diagnostic consideration. more masses may be identified in the i volved breast. A poorly dif-
Inflammato y carcinoma represents 1% of all breast cancers, and ferentiated invasive ductal carcinoma, with associated tumor
patients usually present acutely with rapidly developing symptoms emboli in dilated dermal lymphatics, is the most common finding i
that simulate those of an inflammato y process. Inflammato y car- women with inflammato y carcinoma. The presence of tumor in
cinoma is primarily a clinical diagnosis considered in patients who dilated lymphatics is identified in appr ximately 80% of w omen
present describing the rapid development of diffuse breast changes with clinical signs and symptoms of inflammato y carcinoma.
PATIENT 18
Figure 3.18. Diagnostic evaluation, 37-year-old patient presenting with a “lump” in the left breast.
tomatic breast is done, if the patient has had a mammogram within

At this point, what can you say and with what degree of
the last 6 months. Based on these initial images, additional spot
certainty? compression or double spot compression magnification vi ws may
What else would you tell the technologist to do? be done. Depending on the location of the focal finding, and th
appearance of this area on the spot tangential vie w, correlative
No abnormality is apparent on the craniocaudal (CC) and medio- physical examination and an ultrasound are usuall y indicated. The
lateral oblique (MLO) views. In women over the age of 30 y ears ultrasound may be deferred in patients in whom there is no chance
who present with a “lump” or other focal symptom (focal pain, skin the lesion has been excluded from the field of vi w and completely
changes, etc.), a metallic BB is placed at the site of focal concer n fatty tissue or a benign lesion (e.g., an oil c yst) is imaged, corre-
and CC and MLO views, as well as a spot tangential view at the site sponding to the area of concern.
of the focal abnormality, are done. A unilateral study of the symp-
C Figure 3.18. (Continued) Spot tangential (C) view done at the site of the pal-
pable finding in the upper outer quadrant of the left breast
cyst or a fibroadenoma (consequent y, it can be seen with the more

At this point, what can you say and what is your
rapidly growing malignant lesions). Other benign considerations in
differential? this patient include tubular adenoma, papilloma, pseudoangioma-
tous stromal hyperplasia (PASH), focal fibrosis, galactocele, p yl-
A 1-cm, round mass with w ell-circumscribed margins is demon-
lodes tumor, posttraumatic fluid collection, or an abscess. I vasive
strated on the spot tangential view. A partial halo sign is seen (arrow,
ductal carcinoma not otherwise specified and medulla y carcinoma
Fig. 3.18C). The halo sign, defined as a 1- to 2-mm sha p radiolu-
are the primar y malignant considerations for a patient this age.
cency partially or completely outlining a mass, is a good sign that a
Mucinous carcinomas are typicall y smaller and more common in
lesion is benign. The halo sign is as good a sign that a lesion is
older, postmenopausal women, as are papillary carcinomas. Invasive
benign as spiculation is a sign of malignancy. Some lesions demon-
lobular carcinomas do not typically present as a round mass and are
strating a halo sign turn out to be malignant, but most are not; some
more common in older, postmenopausal women.
spiculated masses turn out to be benign, but most are not. The halo
sign is thought to reflect a rapidy growing lesion, most commonly a
D Figure 3.18. (Continued) Ultrasound image (D) of the

palpable mass in the upper outer quadrant of the left breast.
ing is not breast cancer. So I make it a point of looking them in the

eye when I specifical y tell them: “The lump y ou are feeling is not
What BI-RAD® category would you assign? breast cancer, it is a cyst, a fluid poc et in your breast, and it will not
Would you do anything else? turn into cancer.” However, you still ha ve to assess e very patient
individually for her response to this infor mation. If I sense contin-
On physical examination, a superficial, discrete, har , readily ued concern, I will discuss doing an aspiration. Included in this dis-
mobile mass is palpated at the 1 o’clock position, 1 cm from the left cussion is the likelihood of recurrence following aspiration and the
nipple. A well-circumscribed, 1.3-cm, anechoic mass with posterior small risk of causing bleeding or infection.
acoustic enhancement is imaged, corresponding to the palpable find Aspirated fluid m y be variable in appearance. The fluid m y be
ing. This is a simple cyst. Reverberation artifact (arrow, Fig. 3.18D) free-fl wing and range from clear or opaque serous to g reen to
is present superficial y. In this patient, no further intervention is war- almost black. In some women the fluid is thick and gelatinous; i
ranted unless there is significant tende ness or the patient requests these patients, aspiration may be incomplete even with an 18G nee-
an aspiration. Part of our job is to educate women. So, it is important dle. I do not routinely submit the fluid for ytology unless I obtain
to tell women that cysts are common (i.e., most women have them at grossly bloody fluid after an atraumatic tap.
some point in their life), often multiple, and ma y fluctuate in siz BI-RADS® category 2: benign finding. Annual screening mam-
and associated tender ness. But w hat are these patients w aiting mography is recommended star ting at age 40 y ears unless there are
specifical y to hear from you? They are hanging on your every word, intervening or persistent clinical concerns requiring earlier evaluation.
waiting for you to tell them with confidence that hat they are feel-
PATIENT 19
Figure 3.19. Diagnostic evaluation, 42-year-old patient presenting with a “lump” in the left breast. Craniocaudal
(A) and mediolateral oblique (B) views, with a metallic BB on the palpable abnormality.
D
C
Figure 3.19. (Continued) Spot tangential (C) view of palpable finding

E Ultrasound images (D, E), antiradial (ARAD) projections tak en through
two different areas of the palpable (PALP) mass.
How would you describe the imaging findings? What is your differential, and what is your
recommendation to the patient?
Scattered lymph nodes are noted bilaterall y, superimposed on the
pectoral muscles. Focal parenchymal asymmetry is incompletel y More common diagnostic considerations include an inflammato y
imaged at the site of concer n to the patient, inferomediall y in the process or posttraumatic changes; rare benign lesions to consider
left breast. On ph ysical examination, a tender, hard, fi ed mass is include a papilloma, sclerosing adenosis, g ranular cell tumor, or
palpated just above the medial-most e xtent of the inframammar y fibromatosis (particularly with a lesion in close pro ximity to or
fold on the left. This is associated with some dimpling of the over- associated with the pectoral muscle). Invasive ductal carcinoma not
lying skin. A vertically oriented mass, with spiculated and angular otherwise specified and i vasive lobular carcinoma are the primary
margins and some shadowing, is imaged corresponding to the pal- malignant considerations. Rarely, ductal carcinoma in situ can present
pable finding at the 8 o’clock position, 12 cm from the left nipple as a mass, asymmetric density , or distor tion in the absence of
microcalcifications. Given the described clinical and imaging find

What is fibromatosis (extra-abdominal desmoid), and
ings, a biopsy is indicated.
what is critical in the management of patients
be considered. diagnosed with fibromatosis?
Fibromatosis (extra-abdominal desmoid) is reported histologically
on the cores. The diagnosis is confi med following excisional biopsy. Fibromatosis is an uncommon tumor accounting for 0.2% of all
primary breast tumors and is indistinguishab le from fibromatosi
occurring elsewhere in the body. The tumor is composed primarily
What are the imaging features of fibromatosis? of spindle cells lacking significant atypia, l w to moderate cellular-
ity, rare mitotic figures and collagen. They do not typically metas-
Mammographically, a spiculated, irregular, noncalcified mass is th tasize, but they can recur locally and be fairly aggressive, particu-
most common finding in omen with fibromatosis. Less common y, larly if the lesion is inadequately excised. Wide surgical excision is
focal parenchymal asymmetry that may have associated distor tion therefore critical in the management of these patients. Fibromatosis
can be seen. On ultrasound , the lesions are usuall y hypoechoic, can occur anywhere in the breast, but is often noted in close pro x-
round, oval or ir regular masses with an echo genic rim, posterior imity to the pectoral muscle. Nipple retraction has been reported in
acoustic shadowing, and margins that are not w ell circumscribed. lesions close to the nipple. In some patients, this lesion is associ-
Less commonly, well-circumscribed margins and posterior acoustic ated with Gardner syndrome. An association with trauma and sili-
enhancement may be seen. In a limited number of case reports, these cone implants has also been repor ted. Although they are typically
lesions described as hetero geneous on MR imaging, with lo w to painless, they can be tender, as in this patient. Histolo gically, it is
high signal intensity on T2-weighted images, isointense on T1- important to distinguish these lesions from fibrosarcomas that ca
weighted images, with moderate to strong enhancement follo wing metastasize.
contrast administration. In our experience, the enhancement of these
lesions is variable, and some may not enhance significant y on MR.
PATIENT 20
Figure 3.20. Diagnostic evaluation, 42-year-old patient with a history of Ewing sarcoma of the spine 15 y ears ago, previously treated
with radiation therap y, and right breast cancer treated with lumpectom y and radiation therap y 3 y ears prior to this mammo gram.
toral muscle, consistent with the histor y of a right breast cancer 3

What do you think?
years that w as previously treated conser vatively. Do y ou see a
What recommendations would you make to this
potential abnormality in the left breast? How about additional eval-
patient? uation before making any recommendations?
The right breast is smaller compared to the left, and sur gical clips
are present on the mediolateral ob lique view, anterior to the pec-
C D
E F
Figure 3.20. Craniocaudal (C) and mediolateral oblique (D) spot compression views, left breast. Ultrasound images, in radial (RAD) (E) and antiradial
(ARAD) (F) projections of the lesion at 6 o’clock in zone 3 (Z3).
BI-RADS® category 4: suspicious abnor mality—biopsy should

How would you describe the finding, and what
be considered. An ultrasound-guided biopsy is under taken. A com-
differential considerations would you entertain? plex ductal carcinoma in situ (DCIS) is reported on the core samples.
What is your recommendation? A complex DCIS measuring 1.1 cm is confi med on the lumpectomy
specimen. No invasion is reported. Two excised sentinel lymph nodes
A 1.2-cm irregular mass with areas of lobulation, as w ell as indis- are normal [pTis(DCIS), pN0(sn) (i), pMX; Stage 0].
tinct and ill-defined ma gins, is confi med on the spot compression Pleomorphic calcifications, pa ticularly when individual calci-
views. This is a vertically oriented hypoechoic mass with indistinct, fications are linear, or when linear, round, and punctate calcifica
partially microlobulated, spiculated, and angular margins on ultra- tions demonstrate linear orientation (distribution), are the most
sound. The mammographic and sonographic findings are sugges common mammographic findings associated with DCIS. Rare y,
tive of an ongoing malignant process, particularly in a patient with DCIS can be detected mammo graphically as a mass (w ell cir-
a personal histor y of breast cancer . Differential considerations cumscribed to spiculated, and in some patients macrolobulated),
include a metachronous in vasive ductal carcinoma not otherwise focal parenchymal asymmetry, or distor tion in the absence of
specifie , invasive lobular carcinoma, l ymphoma, or a metastatic calcifications. Clinically, some patients diagnosed with DCIS
lesion. Rarely, ductal carcinoma in situ can present as a mass, present with a palpab le mass, spontaneous nipple dischar ge
asymmetric density, or distortion in the absence of microcalcifica (which can be clear or serous, ne gative for occult b lood) or
tions. Benign considerations include an inflammato y process or Paget’s disease of the nipple.
posttraumatic changes, focal fibrosis, a papilloma, sclerosin
adenosis, granular cell tumor, and an extra-abdominal desmoid. A
biopsy is indicated.
PATIENT 21
B
Figure 3.21. Diagnostic evaluation, 64-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A)
and mediolateral oblique (B) views, metallic BB at site of clinical concern.
C Figure 3.21. (Continued) Spot tangential

(C) view, right breast mass.
abscess. Malignant considerations include in vasive ductal carci-

What is your differential, and what is the next
noma not otherwise specifie , mucinous carcinoma, papillar y car-
appropriate step in the evaluation of this patient? cinoma, and lymphoma. A metastatic lesion is also a consideration,
particularly if there is a histor y of an underl ying malignancy
A 2.5-cm oval mass with indistinct margins is imaged at the site of
(melanoma, lung, renal, colon, etc.), although, in the differential for
concern to the patient, laterally in the right breast. Benign differen-
a round, well-circumscribed mass, medullar y carcinoma is less
tial considerations based on the mammo graphic finding include
likely given the patient’s age. Invasive lobular carcinomas do not
cyst (a galactocele is unlik ely in a 64-y ear-old woman), fibroade
usually present as round or oval masses. Correlative physical exam-
noma (complex fibroadenoma, tubular adenoma), p yllodes tumor,
ination and an ultrasound are undertaken.
papilloma, nodular adenosis, pseudoangiomatous stromal h yper-
plasia (PASH), focal fibrosis, posttraumatic fluid collection, a
D E
Figure 3.21. (Continued) Ultrasound images in radial (RAD) (D) and antiradial (ARAD) (E) projections of the palpable (PALP) finding, right breast
Poorly differentiated, necrotic, invasive ductal carcinomas often

How would you describe the findings and further
present as round or oval, circumscribed (as opposed to spiculated),
evaluate this patient? solid masses with posterior acoustic enhancement and associated
cystic changes (reflecting the necrotic tumor). A rim of poorly dif-
A hard mass is palpated at the 10 o’clock position, posteriorly (Z3) in
ferentiated invasive ductal carcinoma is commonl y present. It has
the right breast. A complex cystic mass with indistinct, microlobu-
been suggested that e xtensive necrosis may be a poor pro gnostic
lated, spiculated, and angular margins is imaged corresponding to the
factor, particularly because nearl y 50% of patients with necrotic
palpable mass. Given the mammographic and sonographic findings
tumors have axillary nodal metastases and the tumors are aneuploid
a poorly differentiated, invasive ductal carcinoma with necrosis is the
and typically lack estro gen and pro gesterone receptors, as
leading diagnostic consideration. A stepwise approach is taken in the
described for this patient. It ma y be that these tumors are prolifer-
evaluation of this patient. The first step is to attempt an aspiration. I
ating so rapidl y that the y are outstripping their v ascular (angio-
no fluid is obtaine , or there is a residual abnor mality after the aspi-
genetic) supply.
ration, an ultrasound-guided core biopsy is done. Although it is
Lymphovascular space in volvement is described in appro xi-
unlikely, if nonbloody fluid is aspirated and no residual abno mality
mately 15% of patients with invasive ductal carcinoma. It has been
is seen on ultrasound, a pneumocystogram can be done to e valuate
described as an unf avorable prognostic finding, particularly in
for the presence of mural abnor malities. Only a small amount of
node-negative patients treated with either mastectomy or lumpec-
bloody fluid is aspirated in this patient. A core biopsy is done.
tomy. The significance in patients with posit ve axillary lymph
BI-RADS® category 4: suspicious abnormality—biopsy should be
nodes (such as our cur rent patient) is not clear . Extracapsular
considered. An invasive ductal carcinoma with necrosis is reported on
tumor extension in involved lymph nodes has also been described
the core samples. A 3.2-cm, g rade III invasive ductal carcinoma is
as an unfavorable prognostic factor, and some consider this findin
diagnosed on the lumpectom y specimen. Lymphovascular space
an indication for axillar y irradiation, particularly in patients w ho
involvement is present. Malignant cells are described on the imprints
have not had an axillary dissection. The presence of metastatic dis-
from one of tw o sentinel lymph nodes; a full axillar y dissection is
ease in axillary lymph nodes, however, is the single most impor-
completed at the time of the lumpectom y. Metastatic disease with
tant prognostic factor, and there is a direct correlation between the
extracapsular extension is described in volving the sentinel l ymph
number of positive lymph nodes and disease-free sur vival as well
node. No metastatic disease is diagnosed in 14 additional e xcised
as mortality.
lymph nodes [pT2, pN1a, pMX; Stage IIB]. The tumor is aneuploid
and negative for estrogen and progesterone receptor expression.
PATIENT 22
A B
Figure 3.22. Diagnostic evaluation, 76-year-old woman called back for further evaluation of the axillary lymph nodes. Spot compression (A, B) views, left
axilla. Similar findings are noted in the right axilla (not sh wn).
nodes, this is exceedingly rare (i.e., one would not expect metasta-
tic disease to an axillary lymph node to reflect an intraductal, non
differential? invasive process).
Several axillary lymph nodes present with punctate, round , and
amorphous forms of a high-density material (lacelik e in appear- Is there any other possibility to consider?
ance). Although they are some what high in density , these ma y
reflect calcifications. Granulomatous diseases including histoplas The alternative possibility is that this material is not calcium and ,
mosis, tuberculosis, and sarcoid in volving axillary lymph nodes given the high density of the material, this should be suspected. In
may calcify; ho wever, calcifications reflecting ranulomatous the past, patients with rheumatoid ar thritis have been treated with
changes are usually coarse, dense, and lar ger that what is seen in systemic gold. Mammographically, the gold can be seen deposited
this patient. Metastatic disease from o varian or thyroid papillary- bilaterally in all of the visualized intramammar y and axillar y
type primaries can present with round , punctate, and amor phous lymph nodes. Given the bilateral involvement of all lymph nodes in
calcifications involving one or se veral axillary lymph nodes. In this patient, the next appropriate step is to talk to the patient and ask
these diseases the calcifications usual y reflect psammoma bod her if she has rheumatoid ar thritis and if she has been treated with
formation in the tumor . Lastly, calcifications m y be seen in the gold. The answer is yes, she has rheumatoid ar thritis and she has
lymph nodes involved with metastatic disease from a breast pri- been treated with systemic gold. No further intervention or follow-
mary. These typically represent calcifications d veloping in a up indicated.
necrotic tumor. Although there have been repor ts of ductal carci- BI-RADS® category 2: benign finding. Annual screening mam-
noma in situ with associated calcifications in the axilla y lymph mography is recommended.
PATIENT 23
Figure 3.23. Diagnostic evaluation, 88-year-old patient presenting with tender “lumps” bilaterally. Craniocaudal (A) and
effect of placental estrogens. As many as 60% to 70% of puber tal

What do you think?
boys (ages 12 to 15) present 1 to 2 years after testicular enlargement
In reviewing films, what information do you look at? begins with gynecomastia that typically regresses within 2 years of
onset. Lastly, in older males, as testosterone le vels decrease, and
There is a dense fibr glandular pattern. No focal abnor mality is
particularly in those with a body mass index greater than 25 kg/m2,
apparent. In reviewing films ou should routinely review the name
breast enlargement may be seen.
of the patient, date of birth, and the technical factors used to obtain
the image (e.g., kilo voltage, milliamperage, centimeters of com-
pression, angle of ob liquity used for the mediolateral ob lique What are some of the conditions that should be
view). Remember: Make no assumptions. Although most patients considered in a male presenting with gynecomastia
who present with a breast-related prob lem are women, not all are. who does not fall into one of the three categories of
By verifying the name of the patient (and talking with the technol- physiologic gynecomastia?
ogist), you can establish that this is a male patient presenting with
tender, bilateral “lumps.” The lumps the patient is describing reflec Pathophysiologic causes of gynecomastia can be considered in several
the presence of breast tissue. He has de veloped gynecomastia and major categories, including (1) estro gen excess (tumors including
requires no additional imaging evaluation or follow-up. Leydig, Sertoli, and g ranulosa-theca cell tumors, choriocarcinoma,
BI-RADS® category 2: benign finding. seminoma, teratoma, embr yonal cell, hepatoma, and pituitar y and
Male patients who present for breast imaging are usually sympto- feminizing adrenal tumors), (2) androgen deficien y (primary testicu-
matic and describe uni- or bilateral breast enlar gement, a mass, or lar failure—e.g. Klinefelter’s syndrome—secondary testicular failure
focal tenderness. Our role with these patients is to exclude an under- from trauma, orchitis, cryptorchidism, irradiation, hydrocele, or varic-
lying malignancy. Depending on the underl ying process, mammo- ocele), (3) drug related (anabolic steroids, diethylstilbestrol, digitalis,
graphic findings will ary. In men with gynecomastia, glandular tis- estrogen, heroin, marijuana, cimetidine, diazepam, k etoconazole,
sue is imaged centered on the subareolar area. The amount of tissue phenytoin, spironolactone, amiodarone, bumetanide, busulf an, calci-
can vary from a few trabecular strands to dense tissue indistinguish- tonin, furosemide, isoniazid, methyldopa, nifedipine, reserpine, theo-
able from that seen in some w omen. The findings m y be uni- or phylline, tricyclic antidepressants, v erapamil, finasteride), (4) sys
bilateral, symmetric or asymmetric in appearance. The diagnosis of temic diseases (hyperparathyroidism, cirrhosis, chronic renal failure,
gynecomastia is established mammographically; sonography is not chronic pulmonary disease, acquired immunodeficien y syndrome
usually indicated. On ultrasound , gynecomastia has a v ariable [AIDS] and human immunodeficien y virus [HIV] infection, and
appearance. It is often an ir regular area of h ypoechogenicity cen- chest wall trauma) and (5) idiopathic.
tered in the subareolar area. Pseudo gynecomastia may be seen in
obese men as breast enlar gement characterized b y adipose tissue
with no associated glandular tissue. What histologic features are associated with the two
The mammographic presentation of male breast cancer is similar main phases of gynecomastia?
to that described in women and includes a spiculated or round mass
that may have associated pleomor phic microcalcifications. Les Gynecomastia is characterized histologically by an active, florid prolif
commonly, distortion or asymmetry may be seen. The lesions may erative phase of ducts and an inacti ve fibrous phase. Epithelial prolif
be subareolar, or more eccentric in location. eration with papillary and cribriform-like patterns, associated myoep-
ithelial cell h yperplasia, and increased cellularity of the periductal
stroma with increased vascularity is described in the florid proliferatve
What is gynecomastia, and is it considered a risk phase. Within 1 to 2 years of onset, the epithelial proliferation becomes
factor or a precursor for the subsequent development much less prominent and dense fibrous stroma with sparse cellularit
of male breast cancer? Do these patients require and decreased vascularity are present. Pseudogynecomastia is charac-
mammographic follow-up? terized by adipose tissue with no ductal or stromal proliferation.
Gynecomastia reflects the proliferation of ductal and stromal tis

sue in male patients. It can present as unilateral or bilateral What component of female breast tissue is not
(simultaneously or at different times) diffuse breast enlargement typically seen in men who develop gynecomastia
that may be associated with tenderness or as a “mass” centered in (consequently, what group of pathologic processes is
the subareolar area. Gynecomastia is not considered to be a risk rare in men)?
factor or a precursor lesion for the de velopment of male breast
cancer. If the clinical and mammographic findings are consisten Lobule formation is not typicall y seen in otherwise nor mal men.
with gynecomastia, I do not recommend an y additional imaging Consequently, lobular processes such as f ibroadenomas, cysts,
studies or follow-up. sclerosing adenosis, and in vasive lobular carcinoma are rare in
men. Ductal and stromal processes such as papillomas, duct ecta-
sia, pseudoangiomatous stromal hyperplasia, apocrine metaplasia,
In what groups of males can gynecomastia be seen as and squamous metaplasia have been reported in men and in asso-
a “physiologic” change? ciation with gynecomastia. Inflammator y processes, epider mal
inclusion cysts, lipomas, intramammar y lymph nodes, g ranular
Physiologic gynecomastia related to hor monal imbalances can cell tumors, and fat necrosis related to trauma can also affect male
occur during three dif ferent phases in male patients. In ne wborn patients, with presentations similar to those described in women.
males, rapidly regressing gynecomastia is common and reflects th
that in most men, a conser vative approach is appropriate because

What management options are available for men with
spontaneous regression is common. Reassurance that the process is
gynecomastia? benign may be all that is needed. Ho wever, several medical treat-
ments have been reported, with variable responses (and associated,
At the time of presentation, it is impor tant to e xclude a serious
sometimes, with significant side e fects), including the use of dihy-
underlying cause of gynecomastia (e.g., an estro gen-secreting
drotestosterone, danazol, and tamo xifen. The surgical option of a
tumor). Treating (or removing) the underlying cause is appropriate
simple mastectomy is available; however, cosmetic results may not
for those men in whom the cause of the gynecomastia is identified
be optimal. More recently, liposuction has been used to treat some
In considering treatment for those patients in w hom no definit
men with gynecomastia.
cause for the gynecomastia is identifie , it is important to recognize
PATIENT 24
A B
Figure 3.24. Screening study, 55-year-old woman with implants in a subpectoral location. Implant-displaced, craniocaudal (A) and mediolateral oblique (B)
views, left breast.
interfaces, the strip of tissue betw een the pectoral muscle and
Is this a normal mammogram, or is there a potential
glandular tissue on the MLO vie ws, subareolar areas and medial
abnormality? If there is an area of concern, where is it? tissue on CC views. In evaluating the medial quadrants on the CC
views, do you perceive a subtle asymmetr y with possible distor-
Review the images systematically. Split the images into thirds such
tion on the left, anteriorl y? In re viewing the left MLO at the
that on the craniocaudal (CC) vie ws you focus your attention on
approximate distance back from the nipple, there is also a possible
lateral, mid, and medial tissue, and on the mediolateral ob lique
area of asymmetry with distortion. The significance of this poten
(MLO) views you review the superior, mid, and inferior aspects of
tial finding on these vi ws is unknown. Additional evaluation will
the breasts. Do you see anything? If not, look specifical y for pos-
be helpful.
sible masses, asymmetry, distortion, or calcifications. N w do you see
anything? If you still do not, look in specific places: at–glandular
C D
Figure 3.24. (Continued) Craniocaudal (C) and mediolateral oblique (D) views of the left breast, photographically coned. A box is used to enclose the
potential abnormality.
E F
Figure 3.24. (Continued) Double spot compression magnification vi ws of the left breast, craniocaudal (E) and mediolateral oblique (F) projections.
pable. On ultrasound, a mass with associated shadowing may be seen,

Now how would you describe the findings, and with
but the ultrasound may be normal. This patient has had no surgery or
what degree of certainty can you say that a lesion is trauma to this site, and her ph ysical examination and ultrasound are
present? normal. This is thought to most likely represent a complex sclerosing
lesion.
The additional views are invaluable in helping us establish the pres- BI-RADS® category 4: suspicious abnormality—biopsy should
ence of a lesion. An area of distor tion with long, cur vilinear be considered.
spicules, central lucency, and associated punctate and round calcifi A complex sclerosing lesion with atypical aprocrine adenosis,
cations is confi med on the additional views. At this point, what are columnar alteration with prominent apical snouts and secretions,
your differential considerations and w hat would you recommend and florid epithelial yperplasia without atypia is repor ted on the
next? Differential considerations include f at necrosis, particularly excisional biopsy.
if the patient has had a biopsy or trauma that is localized to this site, Lesions characterized by central sclerosis and surrounding radi-
complex sclerosing lesion (radial scar when less than 1 cm in size), ating epithelial proliferation are refer red to as a radial scar w hen
focal fibrosis, sclerosing adenosis, papilloma, an inflammat y they are 1 cm in size and as complex sclerosing lesions when they
process, invasive ductal carcinoma not otherwise specifie , and are 1 cm in size. Associated foci of sclerosing adenosis, papil-
invasive lobular carcinoma. Although it is some what larger than loma formation, cystic changes, and epithelial hyperplasia may be
most, this could also be a tubular carcinoma. seen in these lesions. Atypical hyperplasia, ductal carcinoma in situ
(usually low nuclear grade), lobular neoplasia, and invasive carci-
How can you sort through this differential and narrow noma have also been reported arising within radial scars but, more
the diagnosis? commonly, in the lar ger complex sclerosing lesions. Identified a
incidental findings on histol gy, radial scars ( 1 cm in size) are
As a starting point, a good history is helpful. Does the patient have a common, multiple, and often bilateral. In contrast, comple x scle-
scar that corresponds to this site? Does she recall an y trauma to this rosing lesions ( 1 cm in size) identified mamm graphically are
site? If there is no scar or trauma localized to this site, fat necrosis is less common, presenting as single, unilateral lesions. It has been
unlikely. Does the patient have any signs or symptoms of inflamma suggested that infarction occurring in areas of pre-existing prolifer-
tion at this site (e.g., er ythema, increased w armth, tenderness)? ative changes ma y account for the histolo gic findings. H wever,
Physical examination is also helpful.Are there any palpable findings these lesions are considered idiopathic and , although the w ord
Complex sclerosing lesions are usuall y not palpable, and normal or “scar” is used for the smaller lesions, these lesions do not reflec
subtle findings are seen on ultrasound. In contrast, i vasive ductal biopsy changes (i.e., they do not occur at prior biopsy sites).
carcinomas of this size are usuall y palpable, and on palpation the The mammographic findings that should suggest a compl x scle-
findings with invasive ductal carcinoma often o verestimate the size rosing lesion include an area of distor tion better seen in one of the
seen on imaging studies (i.e., they feel larger than what is seen on the two standard projections (usuall y the craniocaudal vie w), long
images). On ultrasound, a mass that may have associated shadowing curvilinear spicules that contrast with the shor t stubby spiculation
is likely with an in vasive ductal carcinoma. In vasive lobular carci- seen with man y invasive ductal carcinomas, and central lucenc y.
noma is unpredictable: Physical findings m y be normal, but either Approximately 30% of these lesions ma y have associated round
an area of thickening without a discrete mass or a mass ma y be pal- and punctate calcifications. The findings on ultrasound are ariable
and can be subtle, limited to a small amount of irregular shadowing. biopsy on a lesion and a complex sclerosing lesion is reported his-
Physical examination is often nor mal or limited to some minimal tologically, I recommend excisional biopsy. Others advocate imag-
thickening. ing-guided biopsy of these lesions with no e xcision required if the
The management of w omen with comple x sclerosing lesions biopsy included at least 12 cores, no atypical ductal h yperplasia is
remains controversial. If this entity is suspected based on the clinical reported, and the mammo graphic findings are reconciled with th
and imaging findings, should an imaging-guided biopsy be done, o histologic findings. It is unclear hy there is such confusion in the
is an excisional biopsy the appropriate recommendation? If a com- literature regarding the appropriate management of these lesions.
plex sclerosing lesion is diagnosed follo wing an imaging-guided Could it be that, pro gnostically, the lesions w e identify mammo-
core biopsy, is e xcision required or can the lesion be left in the graphically are not the same as those seen routinely by pathologists
breast? Based on m y experience, approximately 30% of patients as incidental findings in biopsies done for other reasons? The
with complex sclerosing lesions ha ve associated atypical ductal lesions we identify mammographically are not common and almost
hyperplasia, lobular neoplasia, ductal carcinoma in situ (usuall y always measure 1 cm in size; w e do not routinel y identify the
low nuclear grade), or tubular carcinomas. Consequentl y, if I sus- small lesions (i.e., radial scars that measure 1 cm) repor ted as
pect a complex sclerosing lesion based on the clinical and imaging common, benign incidental findings y the pathologist.
features of lesion, I recommend an excisional biopsy. If I do a core
Figure 3.24. Ultrasound image (G) demonstrating high specular echoes and
G subtle shadowing corresponding to the area of mammo graphic concern in the
left breast.
Figure 3.24. Specimen radiograph (H) demonstrating distortion and associ-

H ated punctate calcifications central y as well as in the sur rounding spicules. A
portion of the localization wire is also evident.
PATIENT 25
A B
Figure 3.25. Diagnostic evaluation, 33-year-old patient presenting with a “lump” in the upper inner quadrant of the right breast. Craniocaudal (A) and medi-
olateral oblique (B) views.
better define , and some demonstrate a cur vilinear appearance.

This differential appearance between the two views raises the pos-
sibility of milk of calcium and, although the diagnosis is established
There is a dense fibr glandular pattern with a regional area of cal-
with the current views, a spot compression 90-de gree lateral view
cification in the upper inner quadrant of the right breast. Did y ou
can be done. In this patient, do w e need to do anything else? How
notice that the appearance of the calcifications is di ferent between
about the “lump” she is feeling? Remember not to be lulled b y
craniocaudal (CC) and mediolateral oblique (MLO) views? On the
benign findings and fo get to look at the rest of the mammo gram
CC view, the calcifications are ariable in size, round and not well
and evaluate clinical findings
defined (amorphous); on the MLO view, they are higher in density,
C D
Figure 3.25. Craniocaudal view (C), photographically coned to the medial aspect of the right breast, and 90-de gree lateral spot compression view (D) of
the upper aspect of the right breast, demonstrating the change in appearance of the calcifications on the o thogonal views.
What is indicated next? ity are identified in the dependent po tion of many of the c ysts.
No solid masses are imaged in this quadrant, and there is no dis-
Correlative physical examination and an ultrasound of the palpa- tortion or shadowing. This is a palpable fibro ystic complex with
ble finding are indicated. On p ysical examination, a 2- to 3-cm associated milk of calcium and corresponds to what the patient is
area of globular tissue is palpated , which occupies almost the concerned about. I reassure her that what she is feeling is benign
entire upper outer quadrant of the right breast. It is readily mobile, and that there are no mammo graphic or sonographic findings t
and tenderness is elicited w hen gentle compression is applied at suggest breast cancer.
this site. No skin changes are present. On ultrasound , cysts of BI-RADS® category 2: benign finding.
varying sizes are imaged throughout this area. Foci of echogenic-
E F
Figure 3.25. (Continued) Ultrasound images (E–G), upper inner quad-

rant of the right breast. Cluster of v ariably sized c ysts with associated
G echogenic foci (arrows) corresponding to the calcifications seen mammo
graphically.
PATIENT 26
Figure 3.26. Diagnostic evaluation, 73-year-old patient presenting with changes involving her left breast and back
pain. Craniocaudal (A) and mediolateral oblique (B) views.
leading diagnostic consideration in this patient. Less likely consid-

erations include in vasive ductal carcinoma, l ymphoma, posttrau-
matic changes, or an ongoing inflammato y process. A biopsy is
The left breast is dif fusely abnormal. It is smaller and more dense
indicated. An invasive lobular carcinoma is diagnosed follo wing
than the right. Although the appearance is subtle, the tissue on the left
ultrasound-guided core biopsy. The patient is also found to ha ve a
has a distorted appearance with associated prominence of the trabec-
positive bone scan with l ytic lesions involving the thoracic spine,
ular markings. Diffuse breast changes can be dif ficult to perceive,
consistent with metastatic disease.
particularly if they evolve slowly from one year to the next; however,
A spiculated mass is the most common mammographic finding i
if you prepare yourself by considering this possibility, they become
women with invasive lobular carcinoma, occurring in nearly 40% of
easier to detect. In some patients, it can be hard to decide w
hich of the
patients. Parenchymal asymmetry and distor tion are the ne xt most
breasts is normal. This is why reviewing prior studies and going back
common mammographic findings. These changes ma y be more
to much earlier mammo grams can be useful in indicating the pro-
apparent in one projection, commonly the craniocaudal view. Diffuse
gressive change. Also, when you suspect diffuse changes, consider
changes include a pro gressive shrinkage of the in volved breast or,
the technical f actors used (e.g., centimeters used for compression,
alternatively, diffuse enlargement and reduced compressibility of the
kilovoltage, and milliamperage) for the exposure.
involved breast may be seen. Invasive lobular carcinoma rarely pres-
Diffuse breast changes can be characterized by increased density of
ents as a round or oval mass. Likewise, when an invasive lobular car-
the breast parenchyma, prominence of the trabecular patter n (with a
cinoma is diagnosed following biopsies done for microcalcifications
“spidery” appearance), and skin thickening that results in either a pro-
the calcifications are usual y not found in association with the in va-
gressive decrease (shrinking) or increase in the size of the in volved
sive lesion. The calcifications are found in benign changes such a
breast. Commonly, the af fected breast is less compressib le and
fibro ystic changes, fibroadenoma, and sclerosing adenosis, and th
requires higher kilovoltage and milliamperage for adequate exposure.
invasive lobular carcinoma is an incidental finding. It is impo tant to
On physical examination the left breast is smaller than right (Fig.
emphasize that invasive lobular carcinoma can be subtle clinicall y,
3.26 E). There is distortion medially, dimpling inferiorly, and nipple
mammographically, sonographically, and pathologically (I refer to it
retraction. The left breast is fi m compared with the right, but no
as the “sleaze disease”). The extent of disease is often underestimated
discrete mass is palpated, no tenderness is elicited, and there are no
clinically, mammographically, and sono graphically. In our o wn
peau d’orange changes. On ultrasound (Fig. 3.26 C, D), the tissue
patients, metastatic disease to the axilla is seen in as many as 60% of
at the 1 o’clock position, 2 cm from the left nipple, is distorted, with
patients at the time of presentation.
significant associated shadowing. Invasive lobular carcinoma is the
C D
Figure 3.26. (Continued) Ultrasound images, radial (RAD) (C) and antiradial (ARAD) (D) projections.
E
Figure 3.26. (Continued) Photograph (E) of the breasts in this patient.
PATIENT 27
Figure 3.27. Diagnostic evaluation, 57-year-old

patient with a history of left breast cancer treated with
B lumpectomy and radiation therap y. Craniocaudal (A)
and mediolateral oblique (B) views.
corresponding to the scar site and the area of mammographic concern

How would you describe the findings and what would
at the 1 o’clock position, 12 cm from the right nipple (F ig. 3.27C).
you do next? This patient can be managed conser vatively. The changes often
evolve with complete resolution (F ig. 3.27D, E). Alternatively, the
The left breast is smaller compared to the right, there is prominence
changes stabilize, and in some w omen calcifications can d velop at
of the trabecular markings, and parench ymal asymmetry with dis-
these sites. Given the number of women with breast cancer w ho are
tortion is seen at the lumpectomy site on the left. These findings ar
receiving chemotherapy, you need to be a ware of the changes that
consistent with the history of lumpectomy and radiation therapy on
may be seen following removal of these catheters. These catheters are
the left. Did you notice the mass on the right? A mass with indis-
commonly placed in the upper inner quadrant of the contralateral,
tinct margins is present in the upper central to inner aspect of the
normal breast and removed following completion of chemotherapy. If
right breast posteriorly. Although it is of concern, given its location
you review prior films, the location of the po t-a-catheter can be
(upper central to inner quadrant), the possibility that this is related
established and cor related with the appearance of this ne w finding
to a prior port-a-catheter site should be considered.
The changes we have seen following removal of a catheter include a
On physical examination a healed scar is noted at the site pre-
round mass with w ell-circumscribed to indistinct mar gins, a spicu-
viously occupied by the port-a-catheter in the upper inner quad-
lated mass, focal parenchymal asymmetry, and calcifications that ca
rant of the right breast. An oval, 1-cm mass with a heterogeneous
range from punctate, round , and pleomor phic to those with a more
echotexture, indistinct margins, and a thin tract to the skin is seen
dystrophic appearance.
Figure 3.27. Ultrasound image (C), corresponding to the mass seen mammographically in the right breast and on ph ysical examination
directly over the location of the port-a-catheter.
D E
Figure 3.27. Follow-up mediolateral oblique (D) view and ultrasound (E), left breast, 6 months following that shown in (B, C). There has been almost
complete resolution of the findings noted in (A–C).
PATIENT 28
A B
C D
Figure 3.28. Diagnostic evaluation, 39-year-old woman presenting with a tender mass in the left axilla. Axillary view (A), left axilla.
Ultrasound images (B–D) of the left axilla.
exposure, the patient may develop tender, indurated, erythematous

lymphadenopathy in close proximity to the inoculation site, lasting
differential? 4 to 6 weeks in most patients, although it can persist for up to a eyar.
The most commonly involved lymph nodes groups include axillary,
An oval, well-circumscribed, macrolobulated mass is imaged on the
cervical, submandibular, preauricular, epitrochlear, femoral, and
axillary view, corresponding to the area of concern to the patient; a
inguinal. Although infections are often mild , some patients can
second mass is par tially seen at the edge of the film inferior y. No
develop systemic symptoms including fe ver, fatigue, loss of
associated calcifications are present. On p ysical examination, sev-
appetite, headache, rash, and sore throat. In some patients the infec-
eral hard, movable, exquisitely tender masses are palpated in the left
tion can involve the eye (Parinaud oculoglandular syndrome), with
axilla. On ultrasound, well-circumscribed masses with prominent
a sore on the conjunctiva, redness of the eye, and swollen preauric-
hypoechoic regions and central or eccentricall y located areas of
ular lymph nodes. Rarely, with involvement of the central ner vous
hyperechogenicity are imaged cor responding to the palpab le find
system, encephalitis with high fe ver, coma, and con vulsions can
ings and consistent with lymph nodes. The findings are nonspecif
develop within 6 w eeks following the de velopment of l ym-
and the differential is extensive, ranging from reactive adenopathy to
phadenopathy. Optic neuritis with transient blindness has also been
lymphoid hyperplasia, collagen v ascular disorders (e.g., sclero-
reported. Other rare manifestations include osteolytic bone lesions,
derma, dermatomyositis), rheumatoid arthritis, granulomatous dis-
granulomatous hepatitis, erythema multiforme, thrombocytopenia
eases (sarcoid, tuberculosis, histoplasmosis), human immunodefi
purpura, and mesenteric lymphadenitis. In most patients, however,
ciency virus, human immunodeficien y syndrome, der matopathic,
this is a self-limited process that resolves on its own and requires no
toxoplasmosis, cat scratch disease, metastatic disease (breast or
treatment. Although antibiotics are used in some patients, appropri-
other primary), and lymphoma.
ate antibiotic coverage is not established.
In patients like this, what else might be very helpful in

sorting through the differential? What are the imaging features of cat scratch disease?
How about obtaining a more e xtensive history relative to any other The intramammary and axillary lymph nodes on the side scratched
underlying systemic diseases, and also e xamining the patient? by the cat can enlar ge, increase in density, and lose the f atty hilar
During the ultrasound study, as I am examining the patient, I notice region; however, they typically remain w ell circumscribed. On
several healing scratch marks on her left arm. On questioning her, she ultrasound, the in volved lymph nodes demonstrate prominence,
describes having recently acquired a kitten, with the scratches having thickening, and bulging of the h ypoechoic cortical region and
occurred approximately 2 weeks previously. The suspected diagnosis attenuation, mass effect, or loss of the echogenic focus usually seen
of cat scratch disease is established following serologic testing. in normal lymph nodes.
What is cat scratch disease, how do humans contract What are the histologic features of cat scratch
the disease, and what are the clinical manifestations? disease?
Cat scratch disease is a bacterial infection caused b y Bartonella Histologically, necrotizing granulomas surrounded by lymphocytes
henselae and is transmitted to humans following a scratch, lick (on limited to the lymph nodes are the hallmark of this disease. Gram-
broken skin), or bite from an infected kitten or cat. It is not trans- negative, branching, Warthin-Starr–positive bacilli ma y be seen
mitted from human to human. The infection is more common in the rarely in the necrotic centers. Cultures do not usuall y yield growth
fall and winter months. Within a couple of w eeks following the of the causative agent.
PATIENT 29
A B
Figure 3.29. Diagnostic evaluation, 64-year-old patient presenting with a

“lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B)
views of the right breast. Spot tangential view (C) at the site of the palpable
C
finding. The metallic BB is on the palpable finding
are noted. Correlative physical examination and an ultrasound are

indicated.
you do next?
Glandular tissue is imaged in the right breast, with no apparent

mass or distortion. Scattered dystrophic and ar terial calcification
D E
Figure 3.29. (Continued) Ultrasound images, in longitudinal (LON) (D) and transverse (TRS) (E) projections corresponding to the palpable site at the
12 o’clock position, 5 cm from the right nipple.
ple hard, irregular, readily mobile, discrete, painless palpab le

How would you describe the findings, what is your
masses. Characteristically, dense glandular tissue is imaged mam-
differential, and what is your recommendation?
mographically, and an ir regular mass with dense shado wing is
imaged on ultrasound corresponding to the palpable area. Biopsies
On physical examination, a hard mass is palpated at the 12 o’clock
through these areas are often dif ficult because of the resistance
position, 5 cm from the right nipple. On ultrasound, a 1.2-cm, irreg-
encountered and the inability of the needle to cut through the tissue
ular mass with a hetero geneous echotexture and some minimal
adequately. Given the history of diabetes, vascular calcifications ar
shadowing is imaged cor responding to the palpab le finding
often seen bilaterally. Multiple lesions ma y be present, occur ring
Differential considerations include in vasive ductal carcinoma not
simultaneously or at dif ferent times. Many of these patients ha ve
otherwise specifie , invasive lobular carcinoma, and l ymphoma.
other complications associated with diabetes, including nephropa-
Benign considerations are limited but include fibrosis or an infla
thy, retinopathy, and neuropathy.
matory process. In the absence of focal symptoms, an inflammatoy
process is unlikely. Biopsy is indicated.
BI-RADS® category 4: suspicious abnormality—biopsy should What histologic findings are reported in patients with
be considered. Diabetic fibrous mastopat y is diagnosed on the diabetic fibrous mastopathy?
core biopsy. In these patients, an adequate amount of tissue may be
difficult to obtain because the dense fibrosis m y preclude adequate The lesions are characterized b y dense fibrosis and a predomi
sampling. If inadequate sampling is a concer n, excisional biopsy nantly B-cell lymphocytic infiltrate su rounding ducts, lobules,
should be recommended. and vessels. An autoimmune etiology has been suggested for this
entity.
How do patients with diabetic fibrous mastopathy
present, and in what group of patients is this entity
typically diagnosed?
Diabetic fibrous mastopat y is a rare entity affecting long-standing,

insulin-dependent diabetic patients who present with one or multi-
PATIENT 30
A B
C D
Figure 3.30. Diagnostic evaluation, 62-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral oblique (B) views.
Spot compression (C) view of “lump” in the right breast. Ultrasound image (D) in the radial projection of the palpable finding in the right subareolar area
lar/lymphatic invasion, is confi med on the mastectom y. Four of

eight lymph nodes ha ve metastatic disease, and e xtracapsular
differential? extension is described in one of the positi ve lymph nodes [pT2,
pN2, pMx, Stage IIB].
Given the small breast size, prominent pectoral muscles, and the
fatty pattern on the left, consider that this ma y be a male patient.
This can be confi med by looking at the name of the patient on the What are some of the risk factors for male breast
film. A 2.5-cm round mass, with partially well-circumscribed mar- cancer?
gins, is present in the right subareolar area. There are no associated
calcifications. On physical examination, a hard, nontender mass is Male breast cancer is uncommon, accounting for 1% of all breast
palpated in the subareolar area on the right. On ultrasound, a round cancers. Men with breast cancer present at slightly older ages com-
mass with indistinct and microlobulated mar gins and associated pared to w omen and often ha ve longer duration of symptoms.
posterior acoustic enhancement is imaged cor responding to the Several risk f actors have been postulated for male breast cancer ,
area of concern to the patient. including increased le vels of estradiol and other estro genic hor-
The differential in a male patient is limited. The main diagnostic mones; mumps orchitis (after age 20 y ears); testicular trauma;
consideration in men presenting with a “lump” is gynecomastia; undescended testis; traumatic injury to the breast; cirrhosis; history
however, the clinical and imaging findings in this patient are no of employment in steel w orks, blast furnaces, and rolling mills;
consistent with gynecomastia. If there is a history of trauma or sur- radiation exposure; Klinefelter’s syndrome; the BRCA 2 mutation;
gery, this could represent a posttraumatic or sur gical fluid collec and less commonl y, but repor ted, BRCA1. Gynecomastia is not
tion. An inflammato y process is also in the dif ferential; however, considered a risk factor or a precursor for male breast cancer.
no tenderness is elicited and no skin changes (e.g,. er ythema,
warmth) are noted on exam. Other benign lesions that can be seen
in men include pseudoangiomatous stromal hyperplasia, duct ecta- How do men with breast cancer typically present, and
sia, papilloma, fat necrosis, epidermal inclusion cyst, and granular what forms of breast cancers are typically diagnosed
cell tumor. In the malignant category, an invasive ductal carcinoma
histologically?
not otherwise specified ould be the leading consideration.
Papillary carcinoma is reportedly more common in men; other sub-
Most male patients present with a painless mass that is either sub-
types that may be seen include medullar y, mucinous, and adenoid
areolar or more eccentric (e.g., upper outer quadrant) in location or
cystic carcinoma. If the patient is kno wn to ha ve a malignanc y
describing nipple discharge. Invasive ductal carcinoma not other-
(prostate, hematopoetic, etc.), this could represent a metastatic
wise specified represents near y 85% of all breast cancers diag-
lesion. Because men do not usually have lobules, lobular processes
nosed in male patients. An associated intraductal component ma y
such as fibroadenomas, ysts, sclerosing adenosis, and invasive lob-
be seen in as many as 50% of invasive lesions. About 5% to 10% of
ular carcinomas are rarely seen in men.
patients are diagnosed with intraductal disease in the absence of
invasion. Given the absence of lobular tissue in most males, in va-
What is your recommendation? sive lobular carcinoma is rare. Prostate cancer with metastasis to
the breast can sometimes be dif ficult to distinguish from primar y
A biopsy is indicated and done. An invasive ductal carcinoma is breast cancer, particularly because some prostate cancers are estro-
diagnosed following the core biopsy. A grade III, 2.5-cm invasive gen receptor–positive.
ductal carcinoma not otherwise specifie , with associated v ascu-
PATIENT 31
Figure 3.31. Diagnostic evaluation, 66-year-old patient presents describing changes in her right
breast. Craniocaudal (A) and mediolateral oblique (B) views. The technical factors used for the
routine views are as follows:
Factor RTCC LTCC RTMLO LTMLO

kV 35 28 35 28
mAs 201 319 170 341
Comp (mm) 101 79 94 81
load, invasive ductal carcinoma not otherwise specifie , inflamma

What do you think, and what additional information
tory carcinoma, in vasive lobular carcinoma, or l ymphoma.
would you like? Invasive lobular carcinoma can lead to increases in breast density
and size or a decrease in breast size (the shrinking breast).
The right breast is diffusely abnormal and appears smaller than the
Differential considerations for dif fuse changes that are usuall y
left. The decreased compressibility of the right breast is e videnced
bilateral, although the y can be unilateral, include hor mone
by the increased number of millimeters required for compression.
replacement therapy (e.g., estrogen), weight changes, congestive
Also notable is the 35 kV used to obtain adequate e xposure of the
heart failure, renal failure with fluid verload, and superior v ena
right breast.
cava syndrome. Additional rare benign causes include granuloma-
Differential considerations for dif fuse changes that are usuall y
tous mastitis, coumadin necrosis, arteritis, and autoimmune disor-
unilateral, although rarely can be bilateral, include radiation ther-
ders (e.g., scleroderma). Obtaining a thorough histor y, examining
apy effect, inflammato y changes (e.g., mastitis), trauma (e.g.,
the patient, and doing an ultrasound are often helpful in sor ting
hematoma, edema), ipsilateral axillary adenopathy with lymphatic
obstruction, dialysis shunt in the ipsilateral ar m with fluid ver-
C D
Figure 3.31. (Continued) Ultrasound images (C, D) taken in the radial projection in the upper outer quadrant of the right breast.
Although a BI-RADS® cate gory 2: benign finding is use , the

Based on the ultrasound images alone, what is the
patient is asked to retur n in 3 to 4 months for follo w-up. As this
most likely diagnosis? process resolves, mixed-density masses (f at containing) and oil
cysts may develop; alternatively dystrophic calcifications m y be
Sonographically, the tissue is h yperechoic consistent with h yper-
seen, or the findings m y resolve completely with no intermediate
emia, and the nor mal tissue architecture/planes are disr upted with
stages.
associated scattered fluid collections. The sonographic findings ar
Note that the assessment cate gories should be considered inde-
suggestive of posttraumatic or inflammato y changes. During the
pendent of the recommendation. In this patient the finding is benign
mammogram and when doing the ultrasound, no significant tender
yet a short-interval follow-up is recommended. In patients in whom I
ness is elicited, as would be expected if this were an ongoing bacte-
suspect an inflammato y condition or posttraumatic/surgical changes,
rial inflammato y process. In scanning the patient, the radiologist is
I recommend a 3- to 4-month follow-up. Under these circumstances,
in a unique position to obtain a thorough, accurate history from the
a rapid change in the findings is xpected. Six months is the usual
patient. Indeed, in this patient, the histor y of a car accident with
recommendation for other patients in whom a short-interval follow-
airbag deployment is obtained from the patient as the ultrasound is
up is recommended (e.g., those with assessment cate gory 3—prob-
being done. She describes significant ecc ymosis, diffusely involv-
ably benign lesion—well-circumscribed mass in a w oman with no
ing the breast, following the accident that has no w resolved com-
prior films)
pletely. The findings in this patient are li ely related to the trauma.
PATIENT 32
Figure 3.32. Diagnostic evaluation, 42-year-old patient pre-

senting with a “lump” in the right breast. Craniocaudal (A) and
B mediolateral oblique (B) views. Metallic BB is seen on the cran-
iocaudal view at the site of concern to the patient.
C D
Figure 3.32. (Continued) Craniocaudal (C) and mediolateral oblique (D) spot compression views of palpable abnormality, right breast.
How would you describe the findings, and what are the demonstrates rapid wash-in and wash-out of contrast, consistent with
main differential considerations? a malignancy (Fig. 3.32G). No additional lesions are identified i
either breast on MRI.
The overall density of the breast parench yma on the right is BI-RADS® category 4: suspicious abnormality—biopsy should
increased, and a mass with distor tion is noted in the right cranio- be considered.
caudal view at the site of concern to the patient (metallic BB). The An ultrasound-guided biopsy is done. An invasive ductal carci-
right craniocaudal spot compression view confi ms the presence of noma and ductal carcinoma in situ are diagnosed on the core
a mass with indistinct and obscured margins, associated distortion, biopsy. The patient is treated with neoadjuv ant chemotherapy fol-
and punctate calcifications. Except for some punctate calcific lowed by lumpectomy and sentinel l ymph node biopsy. Residual
tions, the findings on the mediolateral o lique spot compression grade III invasive ductal carcinoma (1.5 cm) and high-grade ductal
view are not striking: No definite mass is seen, there is scallopin carcinoma in situ with central necrosis are repor ted following the
of the tissue, and f at seems to be present, inter mingled with glan- lumpectomy. The sentinel lymph node is nor mal [ypT1c, pN0(sn)
dular tissue. Although tumors are usuall y three-dimensional and (i), pMX; Stage I].
readily apparent on all views, there may be times when the finding Traditionally, neoadjuvant therapy (preoperative chemotherapy)
are more striking in one of the two projections obtained. This is par- has been the treatment of choice in w omen with inflammato y
ticularly true for invasive lobular carcinoma; however, it can also be breast carcinoma. It is being used with increasing frequenc y, how-
seen with in vasive ductal carcinoma. Rarel y, an inflammato y ever, in women with locally advanced cancer. Following therapy, as
process might present with this constellation of findings the tumor is do wnstaged, some of these patients can be treated
On physical examination, a hard fi ed mass is palpated, involving appropriately with breast-conserving surgery. Patients with a com-
the right breast centrally. A 2.5-cm round mass with indistinct, angular, plete histologic remission following neoadjuvant therapy have sig-
and microlobulated margins is imaged at the 12 o’clock position, 2 cm nificant y improved long-term survival compared to those with par-
from the right nipple, corresponding to the palpable finding. Shad wing tial or no response to therapy. Following breast-conserving surgery,
and enhancement are seen as dif ferent areas of the mass are scanned radiation therapy is also used to treat these patients.
(Fig. 3.32E, F). On magnetic resonance imaging (MRI), the mass
E F
Figure 3.32. (Continued) Ultrasound images, in radial (RAD) (E) and

G antiradial (ARAD) (F) projections of the palpable finding in the right breast
Magnetic resonance, subtraction image (G) of the lesion in the right breast.
PATIENT 33
A B
Figure 3.33. Diagnostic evaluation, 77-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and mediolateral ob lique
(B) views, right breast, with a metallic BB placed at the site of the palpable finding
oblique views of the right breast. A spot tangential view at the site
What do you think, and with what degree of certainty
of the palpable finding is done routine y in patients with localized
can you make any recommendations? findings. In some patients, the lesion may be partially or completely
What else might be helpful in evaluating women who outlined by fat on the spot tangential vie w, facilitating detection
present with localized findings? and characterization of the palpable finding
Coarse dystrophic calcifications are present; h wever, no signifi

cant abnormality is apparent on the craniocaudal and mediolateral
C
Figure 3.33. (Continued) Spot tangential (C) view, palpable finding, right breast. Metallic BB used to indicate loca
tion of “lump.”
appears irregular and spiculated, as shown here, it is of concer n and

Now what can you say, and with what degree of
further evaluation is indicated. Dif ferential considerations include
certainty? invasive ductal carcinoma not otherwise specifie , tubular carcinoma,
What is your differential? and invasive lobular carcinoma. Benign considerations include f at
necrosis (posttrauma or surgery), sclerosing adenosis, papilloma, com-
A spiculated mass is imaged on the spot tangential vie w, correspon- plex sclerosing lesion, and inflammato y changes. Rare causes include
ding to the palpable finding. Scalloping of sha ply define , thin Cooper granular cell tumor or fibromatosis ( xtra-abdominal desmoid).
ligaments can be seen at the subcutaneous f at–glandular tissue inter-
face in many women. When a ligament is thick ened, straightened, or
Figure 3.33. (Continued ) Ultrasound image

(D) in the longitudinal projection at the site of
D concern in the upper outer quadrant of the right
breast.
lumpectomy specimen. Extensive perineural invasion is seen. No

How would you describe the findings, and what is
metastatic disease is seen in three e xcised sentinel l ymph nodes
indicated next? [pT1c, pN0(sn) (i), pMX; Stage I].
Tubulolobular carcinomas are classified as a ariant of invasive
On ultrasound, an irregular, hypoechoic, 1-cm mass with spiculated
lobular carcinomas, characterized b y the presence of small, cohe-
and angular margins and associated shadowing is imaged at the 10
sive cells infiltrating the stroma in single files and the f mation of
o’clock position, 7 cm from the nipple.This corresponds to the area
tight tubules (similar to those described for tubular carcinomas but
of concern to the patient and the mammographic finding.
smaller). However, it should be noted that the classification of
lesion with tubules as invasive lobular carcinoma is controversial.
be considered.
Perineural invasion is not a common finding in breast cancer
An ultrasound-guided biopsy is done and an in vasive mammary
(10% of invasive carcinomas) and repor tedly has no pro gnostic
carcinoma is reported on the cores. A 1.1-cm grade I invasive mam-
significance
mary carcinoma with tubulolobular features and associated inter-
mediate-nuclear-grade ductal carcinoma in situ is repor ted on the
PATIENT 34
A B
Figure 3.34. Diagnostic evaluation, 31-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and mediolateral oblique (B) views,
metallic BB placed at the site of the palpable finding (spot tangential vi w, not shown).
C D
Figure 3.34. (Continued) Double spot compression magnification vi ws, craniocaudal (C) and mediolateral oblique (D) projections.
terization of the calcifications and the xtent of disease. A cluster of

How would you describe the findings, and what is
pleomorphic calcifications is imaged co responding to the “lump”
indicated next? described by the patient, b ut no mass is seen mammo graphically.
Correlative physical examination and an ultrasound are undertaken
Given the presence of calcifications on the routine vi ws, double
for further evaluation of the palpable findings
spot compression magnification vi ws are done for further charac-
E F
Figure 3.34. (Continued) Ultrasound images in radial (RAD) (E) and antiradial (ARAD) (F) projections of the palpable finding, left breast
noma in situ with a cribriform pattern and central necrosis is diag-

nosed on the lumpectom y specimen. No in vasion is repor ted. No
differential? metastatic disease is diagnosed in four e xcised sentinel l ymph
nodes [pTis(DCIS), pN0(sn) (i), pMX; Stage 0].
A hard mass is palpated on ph ysical examination. A 1.2-cm oval
Patients with ductal carcinoma in situ (DCIS) can present clinically
hypoechoic mass with indistinct margins and associated calcification
with a palpable mass, spontaneous nipple dischar ge, or Paget’s dis-
is imaged on ultrasound at the 12 o’clock position, 3 cm from the
ease. More commonly, however, DCIS is clinically occult, diagnosed
left nipple. Cooper ligaments are disr upted and there is mass
following the mammo graphic detection of pleomor phic calcifica
effect on the deep pectoral f ascia. Differential considerations
tions, particularly when some of these are linear , or w hen linear,
include fibroadenoma (compl x fibroadenoma with, because o
round, and punctate calcifications demonstrate linear orientation. Les
the associated calcif ications, associated sclerosing adenosis;
commonly, DCIS can be detected mammographically as a mass (well
tubular adenoma), sclerosing adenosis, papilloma, ph yllodes
circumscribed to spiculated, in some patients macrolobulated), focal
tumor, pseudoangiomatous stromal h yperplasia, and in vasive
parenchymal asymmetry or distortion in the absence of calcifications
ductal carcinoma not otherwise specified with associated ducta
The use of sentinel lymph node biopsy (SLNB) in patients with
carcinoma in situ. A ductal carcinoma in situ, with no associated
DCIS remains controversial. It is probably indicated in women with
invasive component, is also a possibility , although less lik ely
DCIS and kno wn microinvasion and in those patients in w hom
given the presence of a palpable mass that is confi med on ultra-
invasive disease is suspected preoperati vely based on the size or
sound. A biopsy is indicated.
imaging features of the DCIS. An alternative approach that can be
taken is to excise the DCIS and, if invasive disease is identified o
be considered.
the lumpectomy specimen, the SLNB is done as a second operative
A ductal carcinoma in situ is diagnosed on ultrasound-guided
procedure.
core biopsy. A 1.4-cm, inter mediate-nuclear-grade, ductal carci-
PATIENT 35
A B
Figure 3.35. Diagnostic evaluation, 40-year-old patient presenting with a “lump” in the left breast. Craniocaudal(A) and mediolateral oblique (B) views,
C D
Figure 3.35. (Continued) Craniocaudal (C) and mediolateral oblique (D) spot compression views of palpable finding
loma, nodular adenosis, pseudoangiomatous stromal h yperplasia

How would you describe the findings, and what
(PASH), focal fibrosis, posttraumatic (or su gical) fluid collection
differential considerations do you have at this point? vascular lesions, granular cell tumor, and abscess. Malignant con-
What would you do next? siderations include invasive ductal carcinoma not otherwise speci-
fie , medullary carcinoma, adenoid c ystic carcinoma, and l ym-
A well-circumscribed, round, water-density mass is imaged cor re- phoma. Although they are included in the dif ferential for round,
sponding to the “lump” described b y the patient. Benign dif feren- well-circumscribed masses, mucinous and papillary carcinomas are
tial considerations based on the mammo graphic finding include unlikely given the patient’s age. Cor relative physical examination
cyst, galactocele (provided the history supports this), fibroadenom and an ultrasound are indicated for further evaluation.
(complex fibroadenoma, tubular adenoma), p yllodes tumor, papil-
E Figure 3.35. Ultrasound image (E) of the palpable (PALP) finding at the
o’clock position, anteriorly (Z1) in the left breast.
Given the ultrasound findings and the additional What are the imaging findings associated with
history provided, how would you manage the patient? galactoceles?
On physical examination, a superficial, discrete, har , readily Women with galactoceles can present in the third trimester of preg-
mobile mass is palpated at the site of concern to the patient. A 1-cm, nancy, during lactation, or even several years following the cessation
round, well-circumscribed, complex cystic mass with posterior of lactation with a mass that ma y be tender. Mammographically,
acoustic enhancement is imaged cor responding to the palpab le galactoceles are often well-circumscribed, round, water- or mixed-
mass. As the ultrasound is being done, the history of a recent preg- density masses but can be characterized b y ill-defined and indis
nancy is elicited from the patient so that a galactocele is a realistic tinct margins, particularly if they are inflammed. Rare y, a fat/flui
possibility. This patient can be managed in one of tw o ways. If the level may be seen. The ultrasound appearance of these lesions is
patient is otherwise asymptomatic, follo w-up in 3 to 4 w eeks is a also quite variable, ranging from well-circumscribed solid or cys-
possibility. Alternatively, if this mass is tender , or the patient tic masses to comple x cystic masses with posterior acoustic
remains concerned after the discussion of possib le etiologies, a enhancement; however, some ma y be indistinct and associated
stepwise approach is taken for further evaluation. The first step is t with significant shad wing. Fluid/fluid l vels may be also seen on
attempt an aspiration. If no fluid is obtaine , or if a residual abnor- ultrasound. If the y are tender, or the diagnosis cannot be estab-
mality is seen after the aspiration, an ultrasound-guided core biopsy lished based on clinical and imaging findings, an aspiration is indi
is done. In this patient, thick milk y fluid is aspirated and no resid cated. If there is a residual abnormality following the aspiration, or
ual abnormality is seen following the aspiration. No fur ther inter- concerns persist re garding the diagnosis, a core biopsy can be
vention or follow-up is indicated. done.
PATIENT 36
Figure 3.36. Diagnostic evaluation, 47-

year-old patient presenting with a “lump”
in the right breast. Craniocaudal (A) and
mediolateral oblique (B) views, right
breast, photographically coned; metallic
B BB seen on the mediolateral ob lique view
at the site of the “lump.”
the lesion may be partially or completely outlined by fat enabling

Based on the routine views, what can be said and with
visualization and characterization.
what degree of certainty?
What would you do next?
No abnormality is perceived on the routine views. A spot tangential

view at the site of the “lump” is helpful in man y patients because
C Figure 3.36. (Continued) Spot tangential (C) view of the palpab le finding
right breast.
An ultrasound-guided needle biopsy is done, and an in vasive

Now what can you say, and with what degree of
mammary carcinoma is diagnosed on the core samples. A 1.3-cm
certainty? grade I in vasive ductal carcinoma with associated inter mediate-
grade ductal carcinoma in situ is repor ted on the lumpectom y.
The spot tangential vie w demonstrates a spiculated mass cor re-
Extensive lymphovascular space involvement is also noted; ho w-
sponding to the area of clinical concern. The differential consider-
ever, four excised sentinel lymph nodes are normal: [pT1c, pN0(sn)
ations at this point include in vasive ductal carcinoma not other-
(i), pMX; Stage I].
wise specified (NOS), tu ular carcinoma, and in vasive lobular
Shrinkage artifact can simulate lymphovascular space involvement
carcinoma. Benign considerations include fat necrosis (posttrauma
as artifactual spaces are created around tumor cells during processing.
or surgery), sclerosing adenosis, papilloma, focal fibrosis, com
Consequently, the diagnosis of lymphovascular space involvement is
plex sclerosing lesion, and inflammato y changes (mastitis). Rare
sometimes difficult and subjecti ve. Lymphovascular space involve-
causes include g ranular cell tumor and fibromatosis ( xtra-
ment is described in approximately 15% of patients with invasive duc-
abdominal desmoid). Unless there is a direct correlation of this area
tal carcinoma and in 5% to 10% of patients with no metastatic disease
to a site of prior trauma or surgery, this finding requires biops .
to axillary lymph nodes. It has been described as an unfavorable prog-
A 1-cm hypoechoic, irregular mass with indistinct and angular
nostic finding, pa ticularly in node-ne gative patients treated with
margins and shado wing is imaged , embedded and disr upting a
either mastectomy or lumpectomy. The presence of extensive lympho-
thickened Cooper’s ligament (Fig. 3.36D, E). The clinical, mammo-
vascular space in volvement in patients with otherwise f avorable
graphic, and ultrasound findings indicate a biopsy is required.
tumors seems to identify a subset of patients with higher systemic
recurrences and mortality rates from metastatic breast cancer.
be considered.
D E
Figure 3.36. (Continued) Ultrasound images of palpab le finding, in longitudinal (LON) (D) and transverse (TRS) (E) projections, at the 9 o’clock
position, 5 cm from the right nipple.
PATIENT 37
Figure 3.37. Diagnostic evaluation, 44-year-old patient presenting with a “lump” in the left breast.
Craniocaudal (A) and mediolateral oblique (B) spot compression views of a “lump” in the left breast.
spersed fat, an asymptomatic, single dilated duct and multiple

(three or more) similar findings distributed random y (circum-
differential? scribed masses, round or oval calcifications in tight clusters or scat
tered individually throughout both breasts).
An oval mass with partially well-circumscribed and obscured margins
If prior films are vailable, they should be re viewed before
is imaged corresponding to the palpable finding. Based on the mam
assigning BI-RADS® assessment cate gory 3 (probab ly benign
mographic findings, benign di ferential considerations include c yst,
lesion, short-interval follow-up is recommended). If a mass is sta-
galactocele, fibroadenoma (tubular adenoma, compl x fibroade
ble or getting smaller, short-interval follow-up is not indicated. If a
noma), phyllodes tumor, focal fibrosis, pseudoangiomatous stroma
mass is solid and enlarging or is new, a biopsy is more appropriate
hyperplasia, abscess, and posttraumatic fluid collection. Malignan
than short-interval follow-up. Also, detected lesions should be eval-
considerations include invasive ductal carcinoma not otherwise spec-
uated with spot compression vie ws and ultrasound (if a w ell-cir-
ified and medullar y carcinoma. Mucinous or papillar y carcinomas
cumscribed mass is a c yst, short-interval follow-up is not usuall y
and metastatic lesions usually present as round or oval masses; how-
indicated) or, in the case of calcifications, magnification v ws so
ever, given the patient’s age, these are less likely considerations.
that the likely benign features of the lesion can be well documented.
A 2.5-cm oval hypoechoic mass with a cystic component is imaged
In patients with probably benign lesions, it is particularly important
corresponding to the palpable finding at the 9 o’clock position, poste
to discuss the findings, the l w likelihood of malignancy, and avail-
riorly in the left breast (Fig. 3.37C, D). Although the margins are well
able options with the patient. Ultimately, it is the patient’s decision,
circumscribed superficial y, this is not so for the deep margins.
and although most opt for 6-month follo w-up, some request that a
biopsy be done for histologic confi mation. Other patients in whom
Would you agree with a BI-RADS® category 3 a biopsy may be appropriate include those in w hom compliance
(probably benign lesion, short-interval follow-up is with the follow-up recommendation is a concern.
In my opinion, there is inconsistenc y in the management of solid ,
recommended) designation for this mass? Why not? If
well-circumscribed, noncalcified masses (i.e., proba ly benign
not, what would you recommend be done next? lesions). Why, if a probably benign solid mass is close to the skin or
develops in a patient with a small breast and is palpab le, do we con-
This lesion does not fit the definition of a prob ly benign lesion, so
sider it a surgical disease, yet if that same mass is deep in the breast or
this designation is not appropriate. The margins are not w ell cir-
develops in a woman with a larger breast and it is not palpab le, is it
cumscribed and the lesion is palpable. A biopsy is indicated and is
acceptable to recommend a 6-month follow-up for the patient? In my
done. A fibroadenoma is diagnosed. The “probably benign” cate-
practice, if the clinical, mammo graphic and ultrasound findings of
gory should be reserved for mammographically detected and fully
mass are consistent with a benign process (e.g., fibroadenoma), an
evaluated lesions that include nonpalpab le, noncalcifie , well-cir-
the patient is comfor table with the option, I recommend a 6-month
cumscribed solid masses, clusters of round or o val calcifications
clinical and sonographic follow-up even if the lesion is palpable.
nonpalpable focal asymmetr y with conca ve margins and inter-
C D
Figure 3.37. (Continued) Ultrasound images (C, D) of palpable finding, left breast
PATIENT 38
A B
What should be the next step?
Double spot compression views in two projections are obtained to

evaluate calcifications (a row) detected in the left breast on the
screening mammogram.
Figure 3.38. Double spot compression magnification vi ws, craniocaudal (C) and mediolateral oblique
(D) projections.
of tightly packed, sharply defined but pleomo phic calcifications

How would you describe the calcifications?
some of which may be linear and uni- or bilateral, focal or re gion-
What would you do next? ally distributed, amorphous calcifications in dense glandular tissue
Alternatively, a mass with variable marginal characteristics, includ-
A cluster of calcifications is conf med on the double spot compres-
ing spiculation and distor tion, may be seen. Some patients ma y
sion magnification vi ws. The images are well exposed, high in con-
present with a palpab le mass, what has been called an “adenosis
trast, and demonstrate the calcifications ell, with no motion blur. The
tumor.” Patients who present with an adenosis tumor are typicall y
calcifications are homogenous in density, with no linear for ms; how-
premenopausal.
ever, they are pleomorphic and therefore a stereotactically guided nee-
Adenosis is qualified y terms that include blunt duct adenosis,
dle biopsy is done. Differential considerations include fibroadenoma
microglandular adenosis, and sclerosing adenosis. Histolo gically,
papilloma, fibro ystic changes including ductal hyperplasia, atypical
adenosis is a lobulocentric proliferative process with hyperplasia of
ductal hyperplasia, sclerosing adenosis and columnar alteration with
epithelial and myoepithelial cells and the sur rounding intralobular
prominent apical snouts (CAPPS), and ductal carcinoma in situ.
stroma. Specifical y, in sclerosing adenosis there is usuall y some
Sclerosing adenosis with associated calcifications is diagnosed on th
atrophy of the epithelial cell component and prominence of myoep-
core samples. This is congruent with the imaging findings and there
ithelial cells. As with fibroadenomas, the glandular component o
fore no further intervention is warranted. Annual screening mammog-
these lesions is more prominent in premenopausal woman, whereas
raphy is recommended starting at age 40 years.
sclerosis predominates in postmenopausal w omen. Interestingly, a
The mammographic presentation of sclerosing adenosis is v ari-
small percentage of these lesions demonstrate perineural and v as-
able. When a patient presents with calcifications, t o distinct pat-
cular extension of the proliferating acini.
terns for the calcifications can be described: one or multiple cluster
PATIENT 39
Figure 3.39. Screening study, 60-year-old

woman. Craniocaudal (A) and mediolateral
B oblique (B) views, right breast, photographically
coned.
taining masses are benign and do not w arrant any additional evalua-
What are your observations, and what would
tion. Anything else? Did y ou notice the w ater-density mass medial
you do next? and posterior to the radiolucent mass (F ig. 3.39D, E, ar rowheads)?
The margins of this mass are indistinct, particularly on the craniocau-
Several observations can be made. There are round and punctate cal-
dal view.
cifications diffusely scattered in the breast parench yma. These are
BI-RADS® category 0: Need additional imaging e valuation. Spot
benign and do not w arrant additional evaluation or intervention. Do
compression views (not shown), correlative physical examination, and
you see the round radiolucent mass at the edge of the glandular tissue
an ultrasound are done for further evaluation of the water-density mass.
(Fig. 3.39C, arrow)? What would you recommend for this? Fat-con-
Figure 3.39. (Continued) Craniocaudal (C) and mediolateral oblique (D) views, right breast, photograph-
ically coned, demonstrate a round , radiolucent mass ( arrows) and an adjacent round , water-density mass
(arrowheads).
E F
Figure 3.39. (Continued) Ultrasound images in the radial (RAD) projection (E, F), 2 o’clock position, 4 cm from the right nipple.
a simple c yst and requires no fur ther intervention. Posterior

What is your diagnosis based on the imaging findings,
acoustic enhancement may not be readily apparent with small cysts
and what BI-RADS® category would you use in your or those deep in the breast.
report? Oil cysts and lipomas may not be distinguishable mammograph-
What recommendation would you make to the patient? ically, because the y are both radiolucent masses. On ultrasound ,
lipomas are h ypo-, iso- to slightl y hyperechoic solid masses. In
On ultrasound, two adjacent masses are imaged at the 9 o’clock contrast, oil c ysts are v ariable in appearance, ranging from ane-
position, 4 cm from the right nipple. The radiolucent mass, seen choic (indistinguishable from cysts) to complex cystic masses, to
mammographically, is a 1.2-cm o val, hypoechoic mass with cir- irregular solid masses with significant shad wing.
cumscribed margins and is consistent with a lipoma.A 0.9-cm oval, BI-RADS® category 2: benign finding. N xt screening mammo-
anechoic mass with circumscribed mar gins is seen adjacent to the gram is recommended in 1 year.
lipoma. Although no posterior acoustic enhancement is seen, this is
PATIENT 40
Figure 3.40. Diagnostic evaluation, 42-year-old patient presenting with a

A “lump” in the right breast. Spot tangential (A) view of the “lump” in the right
breast. Dense glandular tissue is imaged on the routine views (not shown).
Given the presence of dense glandular tissue on the spot tangential

What would you say, based on the tangential view, and
view, correlative physical examination and ultrasound are indicated
what would you do next? for further evaluation.
Dense glandular tissue is imaged on the spot tangential view. In this
patient, no abnormality is readily apparent on the tangential vie w.
B
C
Figure 3.40. (Continued) Ultrasound images (B–D) through different areas of the palpable mass, in the right breast.
commonly, completely) surrounded by subcutaneous fat, enabling

visualization and characterization of a por tion of their margin. If a
what is your differential? What is indicated next? mass or distortion is seen or if, as in this patient, glandular tissue is
imaged on the spot tangential, correlative physical examination and
On physical examination, a discrete, superficial, har , readily
an ultrasound are indicated for further evaluation. Sonography may
mobile mass is palpated at the 8 o’clock position, 4 cm from the nip-
be deferred if completely fatty tissue or a benign finding is image
ple corresponding to the area of concern to the patient. A vertically
on the tangential view corresponding to the area of concer n to the
oriented, hypoechoic mass with angular and microlobulated margins
patient and there is no chance that the lesion has been e xcluded
is seen cor responding to the palpab le finding. Ductal xtension is
from the mammographic images.
noted (Fig. 3.40D, arrows). The clinical and sonographic features of
this lesion suggest malignancy; however, differential considerations
include fibroadenoma (compl x fibroadenoma, tubular adenoma)
What are some of the ultrasound features associated
papilloma, sclerosing adenosis, pseudoangiomatous stromal h yper-
with malignant lesions?
plasia, invasive ductal carcinoma not otherwise specifie , or a
medullary carcinoma. Given the patient’s age, mucinous and papil-
Ultrasound features suggesting a malignant process include a verti-
lary carcinomas are less lik ely. In the absence of a kno wn malig-
cal orientation (i.e., taller than wide), microlobulation, spiculation,
nancy, metastatic disease is also unlikely.
angular margins, shadowing, duct extension, branch pattern, calci-
fications, thick echogenic rim, marked hypoechogenicity, and a het-
be considered.
erogeneous echotexture. Most malignant masses have multiple fea-
A biopsy is done, and an invasive ductal carcinoma is diagnosed
tures suggestive of malignancy. Tubular structures arising from a
on the core biopsy. Two invasive ductal carcinomas (0.8 cm and 0.6
mass can be characterized as duct e xtension or branch patter n,
cm) with high-nuclear-grade ductal carcinoma in situ with central
depending on their relationship to the nipple; this is deter mined
necrosis are repor ted on the lumpectom y specimen. The sentinel
during the real-time por tion of the study. Duct extension refers to
lymph node is negative for metastatic disease [pT1b, pN0(sn) (i),
the presence of h ypoechoic tubular str uctures extending from the
pMX; Stage I].
mass and directed toward the nipple. A branch pattern is present if
the tubular structures arising from the mass are directed away from
Why do spot tangential views in patients who present the nipple. In this patient, a branch patter n is present (Fig. 3.40D,
with localized findings? arrow).
In patients who present with focal symptoms, the spot tangential

view is sometimes helpful because lesions may be partially (or, less
D
Figure 3.40. (Continued)
PATIENT 41

woman called back for calcifications detected on
screening mammogram. Craniocaudal (A) and medio-
lateral oblique (B) double spot compression magnifi
B
cation views.
resolved into punctate calcifications. Di ferential considerations

include fibroadenoma, papilloma, fibr ystic changes including duc-
recommendation? tal hyperplasia, atypical ductal hyperplasia, sclerosing adenosis and
columnar alteration with prominent apical snouts and secretions
A cluster of amorphous (“lacelike”) calcifications is demonstrated o
(CAPSS), and ductal carcinoma in situ (usually a low- or intermedi-
the magnification vi ws. Although the term “amorphous” is used to
ate-nuclear-grade DCIS with no associated central necrosis).
describe these, they actually represent tightly packed, punctate calci-
fications that are be yond the resolution of the images that can be
be considered.
obtained on a patient. When more magnification is used on specime
A stereotactically guided core biopsy is done.
radiographs (because exposure length is not an issue with a speci-
men, more magnification can be obtained), the calcifications can
Figure 3.41. (Continued) Core radiographs (C, D), done as part of the stereotactically guided core biopsy.
is changed from 0.3 to 0.1 mm to overcome the penumbra effect that

What is the difference between these two images, and
results as the object-to-film distance is increased
what caused it? CAPSS with associated calcifications but no atypia is diagnose
on the core samples. CAPSS is being repor ted with increasing
When a biopsy is done for calcifications, a radi graph of the cores is
frequency in biopsies done for round and punctate or amor phous
obtained to make sure that calcifications h ve been excised for his-
calcifications identified mamm graphically. CAPSS in volves the
tologic evaluation. We use magnification technique to radi graph
terminal duct lobular unit and is characterized b y findings tha
the cores. On the first radi graph (Fig. 3.41C), the calcifications ar
include columnar epithelial cells with prominent apical c ytoplas-
indistinct and dif ficult to reco gnize and characterize. When you
mic snouts, intraluminal secretions, and varying degrees of nuclear
detect blurry images, you need to consider suboptimal compression,
atypia and architectural comple xity. Some CAPSS lesions can
patient motion, or an inappropriate focal spot. Ob viously, subopti-
present diagnostic dilemmas for the patholo gist because the spec-
mal compression and patient motion are not considerations on a core
trum of CAPSS ranges from columnar alteration of the epithelial
radiograph. The most likely cause is the use of the 0.3-mm focal spot
cells with or without atypia to findings suggest ve of low-nuclear-
on the magnification vi ws. The repeat image (F ig. 3.41D), done
grade ductal carcinoma in situ (micropapillary). Excisional biopsy is
using the 0.1-mm focal spot, demonstrates the calcifications a
indicated when CAPSS is associated with atypia or there are concerns
sharp, distinct structures, while others remain faint and more “amor-
regarding an underlying DCIS.
phous” in appearance. With magnification technique, the focal spo
PATIENT 42
B
Figure 3.42. Diagnostic evaluation, 41-year-old patient presenting with a “lump” (metal-
lic BB is seen on mediolateral oblique view) in the left breast. Craniocaudal (A) and medi-
Figure 3.42. (Continued) Spot tangential (C) view of the “lump”, left breast.
described by the patient. On the tangential vie w, an oval mass is

imaged, with par tially well-circumscribed and obscured mar gins
you do next? and a “halo” sign associated with a por tion of the mass. A hard,
readily mobile, nontender mass is palpated in the left breast at the
Dense fibr glandular tissue is present. A round mass with obscured
site of concern to the patient.
margins is seen in the left breast, cor responding to the “lump”
D E
Figure 3.42. (Continued) Ultrasound images, transverse (TRS) (D) and longitudinal (LON) (E) projections of the palpable (PALP) mass, 11 o’clock
position, 3 cm from the left nipple.
A biopsy is done, and tubular adenoma is diagnosed on the core

samples. No fur ther intervention is required unless the patient
differential? desires or requests an e xcisional biopsy. Next screening mammo-
A 2.5-cm, oval, hypoechoic, macrolobulated mass with posterior
acoustic enhancement is imaged on ultrasound at the 11 o’clock
position, 3 cm from the left nipple, corresponding to site of the pal- What are the imaging and histologic features of tubular
pable abnormality. Although most of the margins are well circum- adenomas?
scribed, some nodularity of the mar gins is noted on the transv erse
projection. Differential considerations include fibroadenoma (com Tubular adenomas most commonl y present as noncalcifie , round
plex fibroadenoma, tubular adenoma), p yllodes tumor, nodular or oval masses with well-circumscribed or obscured margins mam-
adenosis, pseudoangiomatous stroma h yperplasia (PASH), and mographically and homogeneously hypoechoic with well-circum-
focal fibrosis. A papilloma is an additional consideration, but the scribed margins and possib ly posterior acoustic enhancement on
size of the lesion mak es this less probab le. Malignant lesions ultrasound. The findings are indistinguisha le from those associ-
include invasive ductal carcinoma not otherwise specified an ated with some fibroadenomas. In some patients, tight y clustered
medullary carcinoma. Given the patient’s age, mucinous and papil- punctate calcifications, in isolation or with an associated mass, my
lary carcinomas are less likely, and without a known malignancy, a be seen mammographically.
metastatic lesion is also unlikely. Tubular adenomas are one of se veral adenomatous lesion types
that include fibroadenomas, compl x fibroadenomas, and lactatin
What would you recommend and why? adenomas. Tightly packed glands (acini), with little sur rounding
stroma, characterize tubular adenomas histologically. Although they
Given some of the margins of this lesion on ultrasound, a biopsy is are not common, tightly packed, dense, punctate or irregular calcifi
recommended. cations have been reported in tubular adenomas. Histologically, the
BI-RADS® category 4: suspicious abnormality—biopsy should calcifications reportedly occur within inspissated secretions in
be considered. dilated glands and not in the stroma.
PATIENT 43
Figure 3.43. Diagnostic evaluation, 84-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and
C Figure 3.43. (Continued) Spot compression (C) view, left breast mass.
process, particularly if there is associated tenderness, erythema, or

How would you describe the mammographic findings,
warmth at the site of the mass. Posttraumatic or operative fluid col
and what is your leading diagnostic consideration? lection should be considered if there is a recent histor y of breast
What would you do next? surgery. Lastly, this could represent an atypical presentation for a
cyst or papilloma. Cystic changes are most commonl y associated
Vascular calcifications are present bilateral y—not an unusual find with the perimenopausal period; ho wever, there is a second small
ing given the patient’s age. Although there is a patient-related ar ti- peak in older postmenopausal women, possibly related to increased
fact on the spot compression view, a round mass with indistinct and estrogen levels from adipose tissue or decreases in liver function.
irregular margins is partially imaged in the left breast, cor respon- An ultrasound is done for further characterization of the finding i
ding to the area of concern to the patient. In an 84-year-old patient the left breast. Our routine for patients suspected of a primar y breast
presenting with a palpab le mass characterized b y indistinct mar- malignancy is to e valuate the involved breast in its entirety , looking
gins, the likelihood of an invasive ductal carcinoma not otherwise for additional breast lesions. We also scan the ipsilateral axilla. If
specified is high and has to be the leading diagnostic consideration. potentially abnormal lymph nodes are identifie , a fine-needle aspira
Other possibilities include metastatic disease (par ticularly if the tion or a core biopsy is done to estab lish the presence of metastatic
patient is known to have an underlying malignancy), papillary car- disease. A full axillary dissection (i.e., bypassing the sentinel lymph
cinoma, mucinous carcinoma, or l ymphoma. Although invasive node biopsy) to establish the number of involved axillary lymph nodes
lobular carcinomas are more common in older postmenopausal and neoadjuvant therapy is considered for those patients in whom we
woman, the round shape of this tumor decreases the lik elihood of establish the presence of metastatic disease in the ipsilateral axilla.
this diagnosis. Benign considerations include an inflammato y
D E
Figure 3.43. Ultrasound image, antiradial (ARAD) (D) projection, palpable (PALP) mass, left breast, 3 o’clock position, 7 cm from the left nipple, and
ultrasound image, antiradial (ARAD) (E) projection, left axilla.
and imaging features, metastatic disease in intramammar y or axil-

lary lymph nodes can be suspected in some patients and fine-needl
what are your impressions and recommendations? aspiration or core biopsy can be done to confi m the diagnostic
impression. In patients with a kno wn breast primar y, increases in
On physical examination, a hard, fi ed mass is palpated laterally in
size, density, loss of the fatty hilum, and marginal circumscription
the left breast. There is no associated tender ness, erythema,
(indistinct or spiculated margins) should suggest the possibility of
warmth, or bruising at this site. There is no history of a recent sur-
metastatic disease. On ultrasound, prominence, bulging, lobulation,
gical procedure. On ultrasound , an o val, hypoechoic mass with
and marked hypoechogenicity of the cortical region are all of con-
macrolobulated margins is imaged cor responding to the palpab le
cern, particularly if an echogenic hilar region is not identified or i
finding in the left breast. An oval, hypoechoic mass with a focus of
appears attenuated. In some patients, there is apparent mass ef fect
hyperechogenicity is imaged in the left axilla. The findings suppo t
of what is seen of the echogenic hilar region.
the diagnosis of an invasive lesion, which is likely associated with
If we suspect an abnor mal intramammary or axillar y lymph
metastatic disease to at least one axillary lymph node.
node, a fine-needle aspiration or core biopsy (if this can be don
An invasive mammary carcinoma with focal squamous differen-
safely) of the lymph node is done under ultrasound guidance. In tar-
tiation (possibly a metaplastic carcinoma) is repor ted on the ultra-
geting, we avoid the echogenic hilar region because of the theoreti-
sound-guided core biopsy. Metastatic disease is diagnosed in the
cal possibility that a needle could disrupt the afferent vessels to the
axillary lymph node on fine-needle aspiration. A 1.9-cm, grade III
lymph node, potentiall y having a ne gative effect on the sentinel
invasive mammary carcinoma with squamous dif ferentiation con-
lymph node biopsy if one is to be done at a later date.
sistent with an adenosquamous or metaplastic carcinoma is diag-
nosed on the lumpectomy specimen. Because of the patient’ s age,
no lymph nodes are sampled at the time of sur gery [pT1c, pNX,
pMX; Stage I]. What are the clinical, imaging, and histologic features
associated with metaplastic carcinomas?
What imaging features in a lymph node suggest the Metaplastic carcinomas represent 2% of all breast cancers. They
possibility of metastatic disease? present as a mass described by the patient as having developed rap-
idly and as a relati vely well-circumscribed mass mammo graphi-
As it relates to the imaging appearance of intramammary and axil- cally. In those lesions with osseous metaplasia, dense calcificatio
lary lymph nodes, the overlap between normal and abnormal find may be seen mammographically.
ings can be significant. Changes and fluctuations in size, densi , These are heterogeneous tumors characterized by metaplasia of
and a loss of the f atty hilum mammographically can be related to the epithelial cells into either squamous or mesenchymal type cells
benign reactive changes or metastatic disease, and similarly, normal- (spindle cell, chondroid, osseous, or m yoid). Histologically, these
appearing lymph nodes with a f atty hilum and no appreciab le can be broadl y divided into those with squamous dif ferentiation
change in size or density can be found to have significant metastati and those with heterologous elements such as cartilage, bone, mus-
deposits when excised. However, based on the clinical presentation cle, adipose tissue, vascular elements, melanocytes, and so on.
PATIENT 44
Figure 3.44. Diagnostic evaluation, 61-year-old patient presenting with a “lump” in the right breast. Craniocaudal (A) and medi-
Figure 3.44. (Continued) Spot compression (C) view, craniocaudal projection, right breast.
The left breast is normal. The main benign diagnostic considerations

How would you describe the findings, what is your
in a patient with multiple masses include c ysts, fibroadenomas, an
differential, and what is your most likely diagnosis? papillomas. Metastatic disease, in vasive ductal carcinoma, and l ym-
Why? phoma are the main considerations in the malignant cate gory. In this
patient, the additional finding of a prominent tubular st ucture with
Multiple subcentimeter-sized masses are present in the right breast, as associated coarse calcifications ma es multiple peripheral papillomas
is a dilated tubular structure within which there are two areas of dense, the most likely diagnosis. An ultrasound to e valuate the masses and
coarse calcifications. Clips from a prior su gical procedure with a the “lump” described by the patient is done next.
benign diagnosis are also noted in the right mediolateral oblique view.
D Figure 3.44. Ultrasound image, radial projection (D), palpable finding, righ
breast, 10 o’clock.
complex cystic masses and solid , hypoechoic masses scattered in

How would you describe the finding corresponding to
the breast.
the area of concern to the patient?
A complex cystic mass is imaged corresponding to the palpable find What are the basic histologic features of papillomas?
ing in the right breast. This is confi matory of our initial impression
that the mammo graphic findings represent papillomas. As the Papillomas are characterized histolo gically by the presence of a
remainder of the breast is scanned, additional complex cystic masses vascular core and an epithelial lining similar to that seen in the
and solid hypoechoic masses are seen scattered in the upper outer ducts, contiguous epithelial cells, and intermittent basilar myoep-
quadrant of the right breast. ithelial cells. Proliferative changes, including hyperplasia, atypi-
cal hyperplasia, and ductal carcinoma in situ, have been reported
How do solitary and multiple peripheral papillomas in association with the epithelial lining of papillomas. In contrast
contrast, and what is their significance? to patients with solitar y, more centrall y occurring papillomas
(subareolar), in whom excised surrounding tissue is often b land,
Solitary papillomas most commonly occur in the major subareolar patients with multiple peripheral papillomas often ha ve signifi
ducts and present with spontaneous nipple dischar ge. They can be cant proliferative changes in the tissue sur rounding the papillo-
identified as a solitary mass or a cluster of round and punctate cal- mas. The described proliferative changes include areas of atypical
cifications (with or without an associated mass) on mammography. ductal hyperplasia, lobular neoplasia, and ductal carcinoma in
Coarse, dense, curvilinear calcifications, noted incidental y within situ. These changes may be seen in nearl y 45% of patients, such
dilated ductal str uctures, are also lik ely sclerosed papillomas. that some consider multiple peripheral papillomas as mark er
Peripheral papillomas are usuall y multiple and are detected on lesions. The management of some of these patients can present a
screening mammograms as multiple masses or multiple clusters of dilemma, particularly when the findings are r gional or dif fuse
round and punctate calcifications. Their distribution is variable and and bilateral.
includes clusters in a small area of tissue, se gmental, regional, or Our approach to patients with multiple peripheral papillomas
diffuse involvement of the breast. In some patients, the findings ar that are localized is to do an excisional biopsy. In women with more
bilateral. On ultrasound, the solitary central papillomas may be iden- regional or diffuse findings, e excise any clinically symptomatic
tified as a solid mass within a dilated duct, a complex cystic mass, or area or an y lesion or lesions that change on follo w-up mammo-
a hypoechoic mass indistinguishab le from an y other solid mass. grams or ultrasounds.
Multiple peripheral papillomas are often seen as a combination of
PATIENT 45
Figure 3.45. Diagnostic evaluation, 36-

year-old patient presenting with a tender
“lump” in the left axilla. Mediolateral
oblique (A) views with an ar row denoting
position of metallic BB used to mark “lump.”
B Craniocaudal views (not shown) are normal.
Left axillary view (B).
How would you describe the findings, what is your How does primary breast lymphoma present?
differential, and what would you do next?
Breast lymphoma, classified as an xtranodal lymphoma, repre-
Predominantly fatty tissue is imaged. Scattered benign-appearing sents 0.1% of all breast malignancies and is only considered pri-
lymph nodes are present on the right. A mass that is at least 3 cm in mary when the patient does not ha ve widespread lymphoma or a
size is par tially imaged on the left axillar y view, with associated history of having had l ymphoma elsewhere in the body . Patients
smaller surrounding masses. As is expected on an axillary view, the present with one or multiple masses, more commonl y involving
humeral head (HH) is also par tially seen. The findings in the lef one breast, although some present with synchronous (and
axilla most likely represent adenopathy. A detailed history should be metachronous) bilateral disease. As many as 20% of patients
elicited from the patient. Specifical y, ask about a histor y of lupus, describe night sweats, fever, and weight loss. Axillary adenopathy
rheumatoid arthritis, sarcoid, psoriasis, tuberculosis, human immun- is identified in 30% to 40% of patients. Mamm graphically, one or
odeficien y virus (HIV) infection, recent e xposure to cats (cat multiple masses with well- to ill-defined ma gins are the most com-
scratch disease), an ongoing infectious process, or kno wn malig- mon presentation. Rarel y, diffuse changes that include increased
nancy (lymphoma, breast cancer, melanoma, etc.). Correlative phys- density, prominence of the trabecular patter n, and skin thick ening
ical examination and an ultrasound are done next. may be seen. On ultrasound , a solid, hypoechoic mass is the most
On physical examination, the patient has significant limitation common finding
in the range of motion for her left shoulder and significant tender Most patients with primary breast lymphoma have diffuse large-
ness is associated with any movement of the left arm or palpation of cell lymphoma, B-cell origin, of the immuno globulin M hea vy-
the left axilla. A hard mass with satellite nodules is palpated in the chain type. The age of presentation and the course of the disease are
left axilla. On ultrasound, a round mass that is markedly hypoechoic variable. Histologic type and stage at the time of diagnosis are the
is imaged cor responding to the dominant palpab le abnormality. major determinants of pro gnosis. A second presentation for pri-
During the ultrasound study and follo wing multiple questions, a mary breast l ymphoma is that of a Burkitt-type l ymphoma with
history of HIV infection is elicited from the patient. Although the bilateral breast in volvement, described in pre gnant or lactating
findings may be benign and reacti ve, an ultrasound-guided core patients. This is characterized b y a more rapid and agg ressive
biopsy is indicated. course. Axillary adenopathy is identified in 30% to 40% of patients
BI-RADS® category 4: suspicious abnormality—biopsy should Patients are usually treated with lumpectomy followed by radiation
be considered. A non-Hodgkin B-cell l ymphoma is diagnosed on therapy.
the core biopsy. A CT scan of the chest confi ms adenopathy in the
left axilla; however, no other adenopath y is identified. Similar y,
neck, abdominal, and pelvic CT scans are normal.
C
Figure 3.45. Ultrasound image (C), left axilla.
PATIENT 46
B
Figure 3.46. Diagnostic evaluation, 74-year-old patient presenting with a “lump” in the left
breast. Metallic BB used to mark location of “lump. ” Craniocaudal (A) and mediolateral oblique
(B) views.
C Figure 3.46. (Continued ) Spot tangential (C) view of palpable mass, left
breast.
includes sebaceous c yst, cyst, and papilloma. A hematoma or

abscess would be considerations if there is a history of trauma to this
differential? site, or if there are signs and symptoms of an ongoing inflammato y
process. Malignant considerations include an in vasive ductal carci-
A round mass with mostl y circumscribed mar gins and associated
noma not otherwise specifie , papillary or mucinous carcinoma, or
skin thickening is present corresponding to the site of concern to the
metastatic disease. The mass superimposed on the pectoral muscle is
patient. An oval mass is also noted superimposed on the left pectoral
most likely a lymph node.
muscle inferiorly. The differential for the mass in the left breast
D E
Figure 3.46. Ultrasound images, radial (RAD) (D) and antiradial (ARAD) (E) projections of palpable mass in the left breast at the 8 o’clock position.
fluid (pus or blood) is obtained, or there is a residual abnor mality,

core biopsies are done. In this patient, an in vasive carcinoma with
recommendation? intra- and extracellular mucin is reported histologically. Although a
breast primary is in the dif ferential, the pathologist is concer ned
On physical examination, a hard mass that is fi ed to the skin is pal-
about a metastatic lesion to the breast. A lung primary is identifie
pated at the 8 o’clock position of the left breast. The skin is erythema-
on a CT scan of the chest.
tous, but there is no associated tenderness with compression. On ultra-
Metastatic disease to the breast is not common, however, it typi-
sound, a round mass with a hetero genous echotexture and posterior
cally presents as one or multiple round masses with v ariable mar-
acoustic enhancement is imaged corresponding to the palpable findin
ginal features that range from well-circumscribed to ill-defined bu
in the left breast. Gi ven the erythema, this may represent an inflam
usually not spiculated. The more common primaries to consider
matory process, or possibly a hematoma, but a biopsy is warranted.
include melanoma, lung, colon and renal; prostate cancer is a con-
sideration in male patients.
be considered.
As a starting point, after infiltrating the skin and breast tissue u
to the lesion with lidocaine, y ou can attempt an aspiration. If no
PATIENT 47
Figure 3.47. Diagnostic evaluation, 55-year-old patient presenting with a “lump” in the left breast. Craniocaudal (A) and medio-
lateral oblique (B) views, photographically coned to the area of concern to the patient, left breast.
Figure 3.47. (Continued) Spot tangential (C) view

C of palpable finding. Metallic BB used to mark the pal
pable finding
however, these are more commonly seen in the lateral quadrants. In

establishing an etiology, reviewing prior films and obtaining a his
differential? tory may be helpful. In this patient, a fibroadenolipoma or intra
mammary lymph node is unlikely because her prior mammogram is
A mixed-density (fat containing) mass is imaged in the upper inner
normal. In patients with mixed-density lesions, the benign etiology
quadrant of the left breast at the site of concer n to the patient.
of the finding is esta lished mammographically, and no additional
Differential considerations include a fibroadenolipoma, at necrosis
evaluation is indicated.
related to prior sur gery or trauma, oil c yst, galactocele, or an
BI-RADS® category 2: benign finding
abscess. An intramammary lymph node is also in the dif ferential;
E
D
Figure 3.47. Ultrasound images, radial (RAD) (D) and antiradial (ARAD) (E) projections of the palpable finding in the left breast at the 10 o’clock posi
tion, 12 cm from the nipple.
an inflammato y process unlik ely. Although on questioning the

patient does not recall any trauma to this area, the findings are mos
diagnosis? suggestive of f at necrosis related to trauma. (I include the ultra-
sound for completeness, not because an ultrasound is needed to
An ill-defined round area of slight yperechogenicity with associ-
establish the benign etiology of the mammographic finding.
ated areas of cystic change is imaged corresponding to the palpable
finding. No tenderness is elicited as this mass is palpated , making
PATIENT 48
B
Figure 3.48. Diagnostic evaluation, 78-year-old patient presenting with a tender “lump” in the left breast. Craniocaudal
(A) and mediolateral oblique (B) views with a metallic BB used to mark the palpable finding.
C Figure 3.48. (Continued) Spot tangential view (C) of the palpable finding
left breast.
inclusion cysts have an epider mal cell lining, in contrast to the

epithelial cell lining that characterizes sebaceous c ysts. These are
What do you think is the likely diagnosis, and how can usually readily palpable, well-define , cutaneous or subcutaneous
you confirm your impression? masses that can become quite lar ge and may be visible when they
cause a smooth bulging of the o verlying skin. The orifice of th
A round mass with indistinct margins is imaged in the upper inner sebaceous gland may be visib le as a dark spot (“b lackhead”). In
quadrant of the left breast, cor responding to the “lump” described some patients, a thick white cheesy material can be expressed through
by the patient. On the spot tangential vie w this mass is associated the orifice of the obst ucted sebaceous gland. Mammo graphically,
with the skin and lik ely represents a sebaceous c yst. This can be they are often well-circumscribed masses, commonly in the medial
confi med by examining the patient. On ph ysical examination, a quadrants of the breasts. In some patients the margins are indistinct,
mass that is fi ed to the skin (the mass moves with the skin; it can- particularly if there is associated inflammation. Calcifications y
not be moved independently of the overlying skin) is palpated in the also be seen associated with some sebaceous cysts. On ultrasound,
upper inner quadrant of the left breast. On visual inspection, a the most common finding is that of a ell-circumscribed mass aris-
prominent pore is seen at the center of the palpab le finding. With ing in the skin and commonly extending into the subcutaneous tis-
gentle compression, thick white material can be squeezed out of the sue. They can be anechoic, h ypoechoic, slightly hyperechoic or
visualized pore, confi ming the impression that the palpable findin heterogeneous, and in some patients, a thin h ypoechoic tubular
is a sebaceous cyst. (e.g., a track) structure can be seen extending from the mass to the
BI-RADS® category 2: benign finding. skin surface. Unless the patient is symptomatic, no inter vention is
Sebaceous and epidermal inclusion cysts are clinically, mammo- required. If the patient is symptomatic sur gical excision may be
graphically, and sono graphically indistinguishable. Epidermal indicated.
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Adler DD, Helvie MA, Oberman HA, et al. Radial sclerosing lesion of of Radiology; 2003.
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Cha pter 4
Management
A
D
■ TERMS
Atypical ductal hyperplasia (ADH) Intracystic carcinoma Pneumocystogram
Atypical lobular hyperplasia (ALH) Ipsilateral breast tumor recurrence Positive predictive value (PPV)
Columnar alteration with prominent (IBTR) Prevalent cancer detection rate
apical snouts and secretions (CAPSS) Lobular carcinoma in situ (LCIS) Pseudoangiomatous stromal
Complex sclerosing lesion Lobular neoplasia hyperplasia (PASH)
Cribriform ductal carcinoma in situ Local recurrence Radial scar
Ductal carcinoma in situ (DCIS) Medical audit Regional recurrence
Ductography Micropapillary ductal carcinoma in situ Sclerosing adenosis
E-cadherin Minimal breast cancer Secretory carcinoma
False negative (FN) Mucocele-like lesion Sensitivity
False positive (FP) Multiple peripheral papillomas Specificity
Fibroadenoma Papilloma True negative (TN)
Hyperplasia Papillomatosis True positive (TP)
Incident cancer detection rate Phyllodes tumor
■ MANAGEMENT or magnetic resonance imaging (MRI) finding, does hat you see on
ultrasound correlate with the mammographic or MRI finding? If th
In managing the various situations that arise in breast imaging, it is patient presents with a focal finding, does hat you see mammo-
good to al ways be thinking not just relati ve to w hat the first ste graphically correlate with the described clinical finding? When rec-
should be for your patient’s care, but what the second and third steps ommending an imaging-guided or e xcisional biopsy, consider what
might be as well. Your patient? Yes, your patient. Know and consider you will accept as a diagnosis and w hat you will recommend if the
the cascade of events you precipitate for patients based on what you results are different from those expected. Are the imaging and histo-
say to them, ho w you word your report, and the recommendations logic findings concordant? If the imaging and histol gic findings ar
you make. Are you sure enough about what you are saying to justify benign and congruent, patients can be retur ned to annual screening
whatever ensues for the patient? Is y our decision moti vated by a mammography. For patients diagnosed with a malignancy, MRI and
defensive posture and the recognition, at some level, that the workup surgical consultation are scheduled. If the findings are not concor
is incomplete (substandard) and that y ou are operating with inade- dant, repeat biopsy or e xcisional biopsy is recommended. F or
quate or incomplete infor mation, or one that is justifia ly based on patients with a diagnosis of atypical ductal hyperplasia (ADH), pos-
common sense, a complete workup, and what is good for the patient? sible phyllodes tumor, multiple peripheral papillomas, fibromatosis
or granular cell tumor, wide surgical excision is indicated following
imaging-guided biopsies.
■ CORRELATION The management of se veral types of lesions diagnosed on core
biopsies remains controversial. Included in this g roup are solitary
The need for cor relation in every process undertaken is fundamen- papillomas, lobular neoplasia (atypical lob ular neoplasia, lob ular
tally important. If an ultrasound is done to evaluate a mammographic carcinoma in situ), complex sclerosing lesions, and mucocele-lik e
378 Chapter 4 • Management
lesions. The current consensus is that excisional biopsy is appropri- For potentially abnormal screening mammograms, I state what the
ate when these lesions are diagnosed on core biopsies because of potential abnormality is (e.g., mass, calcifications, disto tion) and in
the reported incidence of associated malignancy and the frequency which breast it is located; I also comment specifical y on the other
with which some of these lesions are upg raded to cancer w hen breast. The description and characterization of the lesion is defer red
more tissue is examined histologically. until a thorough evaluation is completed (e.g., for a mass, spot com-
pression views, physical examination, and an ultrasound). The rec-
ommendation for a w oman with a potentiall y abnormal screening
mammogram is “additional evaluation is indicated and we will con-
■ BREAST IMAGING CONSULTATIONS tact the patient directly to schedule the additional evaluation” (see the
introduction to Chapter 2 for additional discussion). Consequentl y,
As mentioned previously, regardless of the type of study done, the
the only assessment categories used for screening mammograms are
title on the written description of w hat I do is worded as a “Breast
0, 1, and 2.
Imaging Consultation” not a “Radiology Report.” The comprehen-
In the diagnostic setting, I issue one consultati ve report that
sive evaluations that can be undertaken by breast imagers have put
includes the findings for the diagnostic mamm gram, physical
us in a consultative role. A general outline used for breast imaging
examination, and ultrasound. Based on the clinical and imaging
consultative reports includes:
features of a lesion, the findings are described and an impressio
• Type of study (e.g., screening or diagnostic mammogram, with recommendations is generated. The impression is not used to
ultrasound) repeat a description of the findings but rather is used to del ver the
• Reason for study final, clinically relevant concept with what I think is indicated for
• Tissue type the patient.
• Succinct description and location of finding Read your reports critically. Strive for precision (e.g., give meas-
• Impression, with your specific recommendations urements for a lesion and avoid characterizations such as “small” or
• Assessment category (required under the Mammography Quality “large”) and eliminate unnecessary words (e.g., “clearly,” “appears
Standards Act for all mammographic studies) with wording as to be,” “very,” etc.) that pro vide no relevant information and may
provided by the American College of Radiology, Breast Imaging serve to obscure your message. It is important to familiarize your-
and Reporting Data System (BI-RADS®) for mammography: self with the mammo graphy, ultrasound, and magnetic resonance
imaging lexicons provided by the American College of Radiology,
Category 1: negative
Breast Imaging and Reporting Data System (BI-RADS®), as these
Category 2: benign findin
provide guidelines on what should be described for particular find
Category 3: probably benign finding; sho t-interval follow-up is
ings and suggests terminology to be used for relevant findings
recommended
Category 4: suspicious abnormality—biopsy should be con-
sidered
Category 5: highly suggestive of malignancy—appropriate ■ MEDICAL AUDIT
action should be taken
Category 6: known biopsy-proven malignancy—appropriate In breast imaging, accountability needs to be present e very step of
action should be taken the way. Although quality control and data tracking are often rele-
Category 0: need additional imaging evaluation and/or prior gated to the technologist, radiologists should be actively involved in
mammograms for comparison these processes for their practice. It is onl y through monitoring
results that problems can be addressed and much learning can take
Category 4 lesions can be further subdivided at the discretion of
place. We need to kno w how well we are doing, and w e want to
the facility for their internal use into:
identify potential prob lems that can be addressed so that patient
Category 4A: low suspicion for malignancy care is improved. By tracking data and learning from the results, we
Category 4B: intermediate suspicion for malignancy can improve patient care. The numbers generated from the audit
Category 4C: moderate concern should be vie wed not as one point in time b ut rather ho w they
change as you gain more experience.
I make every effort to generate descripti ve but succinct repor ts
Data that should be collected include:
that are clinically relevant and that pro vide specific direction an
recommendations. I use no disclaimers in m y reports, and I do not • Date of audit
abdicate clinical correlation of anything to others. In considering the • Number of screening studies (first-time study vs. repeat screen
wording of repor ts, it is m y contention that if, based on complete • Number of diagnostic studies
clinical and imaging evaluations, you have a high degree of certainty • Call-back (recall) recommendations (e.g., BI-RADS® category
relative to the diagnosis, clear consultative reports with specific rec 0: need additional imaging evaluation)
ommendations can be dictated easily and succinctly (e.g., “a spicu- • Biopsy recommendations (BI-RADS® category 4 and 5: suspi-
lated mass measuring 7 mm is imaged at the 3 o’clock position, cious abnormality and highly suggestive of malignancy)
5 cm from the right nipple. Biopsy is indicated. This is undertaken • Biopsy results (e.g., benign vs. malignant; FNA vs. core biopsy
and reported separately.”). Make up your mind about what you are vs. excisional biopsy)
going to say before you start dictating. Hedges and disclaimers are • Tumor staging: histologic subtype, grade, size, and nodal status
used when we are uncomfortable and uncertain about a finding an
Data that you can calculate include:
its significance. In this situation, I ould suggest that we need to do
whatever it takes to increase our level of certainty so that we can be • True positive (TP): cancer diagnosed within 1 year of a biopsy
more definit ve. recommendation for an abnormal mammogram
• True negative (TN): no known cancer within 1 year of a normal • Specificity TN/(FP TN), or the probability of a normal
mammogram mammogram when no cancer is present
• False negative (FN): cancer diagnosed within 1 year of a normal
mammogram; these should be reviewed and analyzed Based on reports of audit data, obtainable goals include:
• False positive (FP): • PPV1 (abnormal screens): 5% to 10%
FP1 no known cancer diagnosed within 1 year of an abnor- • PPV2 (biopsy recommendations): 25% to 40%
mal screening mammogram for which additional imaging or • Stage 0 or 1 tumors diagnosed: 50%
biopsy is recommended • Minimal cancers (invasive cancer 1 cm or DCIS): 30%
FP2 no known cancer diagnosed within 1 year of a recom- • Node-positive tumors: 25%
mendation for biopsy or surgical consultation based on an • Prevalent cancers/1,000: 6 to 10
abnormal mammogram • Incident cancers/1,000: 2 to 4
FP3 benign disease diagnosed on biopsy within 1 year after • Call-back (recall) rate: 10%
recommendation for biopsy or surgical consultation based on • Sensitivity: 85%
an abnormal mammogram • Specificity: 90%
• Positive predictive value: Published sensitivity rates for mammo graphy range betw een
85% and 90%. Recognize, however, that this is probably one of the
PPV1 percentage of cancers diagnosed following an abnor- harder statistics to obtain because of the dif ficulty of establishing
mal screening mammogram an accurate false negative rate. Access to a statewide tumor registry
PPV2 percentage of cancers diagnosed when a biopsy or sur- can be helpful; ho wever, if the patient mo ves (or seeks medical
gical consultation is recommended following a screening care) out of state, knowledge of a cancer diagnosis may not be read-
mammogram ily accessible to the screening facility.
PPV3 percentage of cancers diagnosed on the actual number The effect of breast imaging and the role of radiolo gists in the
of biopsies done as a result of a screening mammogram management of women with breast cancer goes unstated and , in
• Cancer detection rate for asymptomatic women (i.e., true many ways, is often misrepresented. There is continued sk epti-
screening population) cism and criticisms relati ve to our contributions to patient care
and the significance of hat has already been accomplished: the
Prevalent (rate of cancer detection among women presenting for routine identification of ymph node-negative stage 0 and stage I
their first screening mamm gram) invasive cancers and ductal carcinoma in situ. Recentl y reported
Incident (rate of cancer detection among women with prior decreases in breast cancer mor tality rates are attributed by many
screening mammograms) to more effective treatment, ignoring or relegating to a secondary
By age groups role our ability to detect DCIS, stage 0, and stage I lesions in
• Percentage of minimal breast cancers diagnosed many patients. Is early detection possibly the more important fac-
• Percentage of node-negative breast cancers diagnosed tor, and does not our ability to identify small lesions increase
• Call-back (recall) rate available treatment options and render them more ef fective for
• Sensitivity TP/(TP FN), or the probability of detecting a patients?
cancer when a cancer is present
PATIENT 1
A B
Figure 4.1. Screening study, 60-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, right breast.
papilloma, focal fibrosis, an inflammat y process, invasive ductal

What do you think? What would you do next?
carcinoma not otherwise specifie , tubular carcinoma, and invasive
lobular carcinoma. In discussing the findings with the technol gist,
A mass with a radiolucent center , associated distor tion, and long
she relates not seeing a scar at the site of the spot views. Correlative
spicules is present anteriorly in the upper outer quadrant of the right
physical examination and an ultrasound are indicated next.
breast. Given these features, fat necrosis related to a prior biopsy is
After introducing myself to the patient and briefly describing hat
one of the main considerations. As a starting point, prior films ould
we have seen so far and what I would like to do next, I specifical y ask
be helpful in determining if this finding could be seen pr viously, and
her about prior breast sur gery or trauma. She has no recollection of
what, if any, evolution has occurred. A review of the patient’s history
having had surgery or trauma to the right breast. On close inspection
form, looking specifical y to see if she has had a biopsy at this site,
of the periareolar region, however, a scar is apparent at the edge of the
will also be helpful. Unfor tunately, no prior films are vailable for
areola corresponding to the site of the mammographic finding. I pal
this patient, and nothing is indicated on the history form relative to a
pate no corresponding mass, elicit no tenderness at this site, and the
prior biopsy in the right breast. Additional evaluation is indicated.
ultrasound is normal throughout the subareolar area e xtending into
the upper outer quadrant of the right breast.
The spot compression views confi m the presence of a mass with
As I approached the patient, I remained open to all diagnostic
a low-density central area, distortion, and long spiculation. The dif-
possibilities; however, I had some skepticism relative to the infor-
ferential for this finding includes at necrosis related to prior sur-
mation provided. In my mind, the mammo graphic findings (l w
gery or trauma, comple x sclerosing lesion, sclerosing adenosis,
central density, distortion, and long spiculation), in the absence of Given our total f ascination with technolo gy and images, w e
a palpable finding, ere highly suggestive of fat necrosis or a com- often dismiss or underestimate simple and ine xpensive tools such
plex sclerosing lesion. So, rather than totall y discard m y initial as physical examination, and y et this often pro vides the cor rect
impression, I examine the patient carefully, focusing my attention answer expeditiously. I cannot emphasize enough how many times
on the site of the mammo graphic findings. Although the patient direct communication with the patient and a thorough ph ysical
has no recollection of prior sur gery (patients do not always recall examination provide an efficient means of ar riving at the cor rect
prior surgical procedures, trauma, or inflammator y processes; answer for a given patient. As clinical breast imagers, we are in a
some may not e ven recall a breast cancer diagnosis), and the unique position to integrate clinical, physical, imaging, and histo-
technologist reported no scars, b y spending 2 minutes closel y logic findings to pr vide accurate, optimal patient care. Do not sell
examining the patient, the diagnosis of postoperati ve change is yourself or y our patients shor t by passing up an oppor tunity to
established and no additional inter vention or follow-up is recom- examine and talk to the patient directl y. Do not rele gate physical
mended. examination and the performance of ultrasound studies to others.
C D
Figure 4.1. (Continued) Craniocaudal (C) and mediolateral oblique (D) spot compression views, right breast.
PATIENT 2
Figure 4.2. Diagnostic evaluation, 33-year-old patient presenting with a “lump” in the right
breast. Craniocaudal (A) and mediolateral oblique (B) views, metallic BB used to mark location
of “lump” described by the patient.
Figure 4.2. (Continued) Spot tangential (C) view of the palpable finding, right breast
node. Biopsies of the right breast and axillar y masses confi m the
suspected diagnoses. At the time of her definit ve surgery, a grade
III invasive ductal carcinoma with extensive lymphovascular space
There is dense fibr glandular tissue, and no focal abnor mality is
involvement measuring at least 5.7 cm in size is reported histologi-
apparent on the spot tangential view. Correlative physical examina-
cally. Tumor is also reported in the dermal lymphatics surrounding
tion and an ultrasound are indicated for further evaluation.
the right nipple [pT3, pN2, pMX; Stage IIIA].
On physical examination, a hard, fi ed mass is palpated at the 9
In patients with palpab le findings and no mal-appearing dense
o’clock position, 5 cm from the right nipple. On ultrasound, (Fig. 4.2D,
glandular tissue mammographically, correlative physical examina-
E), an irregular mass with a heterogeneous echotexture, indistinct mar-
tion and an ultrasound are indicated for fur ther evaluation. In this
gins, and areas of shadowing and enhancement is imaged correspon-
group of patients, ultrasound is an excellent adjunctive tool in eval-
ding to the palpable finding This mass measures at least 5 cm. The clin-
uating the clinical findings. If our focus is optimal, e ficient, and
ical and sonographic finding are consistent with a malignant process,
expeditious patient care, then clinical, mammo graphic, and sono-
most likely an invasive ductal carcinoma. A biopsy is indicated.
graphic evaluations and, when needed, imaging-guided biopsies of
the breast and axilla, are done in one visit. With a 24-hour tur n-
What else should you do to evaluate this around time on core biopsy results, histology findings are vailable
patient further? the following day and the patient is scheduled to see the surgeon for
definit ve treatment. As clinical breast imagers, we are in a unique
For patients in whom we suspect a malignancy, we examine the ipsi- position to affect the care our patients recei ve. Evaluations, which
lateral axilla for potentially abnormal lymph nodes. If any potential in many communities take weeks, with significant associated anxi
abnormality is identified in the axilla, a fine-needle aspiration or ety for the patient and her f amily, can be accomplished accuratel y
needle biopsy is also done. P atients with metastatic disease to the in 24 hours. By pro viding this type of ser vice, we also effectively
axilla will under go a full axillar y dissection at the time of the eliminate the fragmentation of care (and with that the potential for
lumpectomy, bypassing the need for a sentinel lymph node biopsy. miscommunication) among providers that can result w hen evalua-
In this patient, an o val hypoechoic mass is imaged in the right tions are carried out over several weeks (e.g., one radiologist doing
axilla (Fig. 4.2F). Given the thickening of the cortex and the lack of the initial mammogram, another doing the ultrasound, and possibly
a hyperechogenic hilar region, this is a potentially abnormal lymph a third doing the biopsies).
E
D
Figure 4.2. Ultrasound images, radial (RAD) (D) and antiradial (ARAD)
F (E) projections, corresponding to the area of concer n to the patient in the right
breast. Ultrasound image (F), right axilla.
PATIENT 3
A B
Figure 4.3. Diagnostic evaluation, 38-year-old patient presenting with a palpable mass in the right breast. Craniocaudal (A) and mediolateral oblique
(B) views of the right breast. Metallic BB used to mark “lump” described by the patient.
C D
E F
Figure 4.3. (Continued) Spot compression vie ws of mass in craniocaudal (C) and mediolateral oblique (D) views. Ultrasound images in radial (RAD)
(E) and antiradial (ARAD) (F) projections of palpable finding at the 6 o’clock position, appr ximately 12 cm from the right nipple.
spot compression view. Why are these not seen on the spot cranio-
What do you think?
caudal view? Did you see them on the routine craniocaudal view, or
was your eye drawn to the clinical finding? Remembe , do not let
A round, solid, 2-cm mass with spiculated , indistinct, and angular
yourself be distracted b y obvious benign or malignant mammo-
margins and associated shado wing is imaged in the right breast,
graphic/clinical findings. E en when you are presented with an
corresponding to the area of concer n to the patient. Although no
obvious finding, ma e sure to evaluate the remainder of the mam-
calcifications are identified associated with the mass on the cranio
mogram and the contralateral side thoroughly.
caudal spot compression vie w, or on the ultrasound , a cluster of
pleomorphic calcifications is vident on the mediolateral ob lique
G H
Figure 4.3. (Continued) Craniocaudal (G) and mediolateral oblique (H) views,
I right breast, photo graphically coned. Doub le spot compression magnification
(I) view, right breast.
represents multicentric disease and a mastectomy is probably indi-

What do you think now? What is your
cated for this patient.
recommendation? Histologically, a complex ductal carcinoma in situ is diagnosed ,
corresponding to the cluster of calcifications seen mamm graphi-
The calcifications project on the mass in the mediolateral o lique cally, and a 2.5-cm, grade III, invasive ductal carcinoma with asso-
view, but they are medial in location on the craniocaudal vie w and ciated lymphovascular space involvement is described for the mass.
at a distance from the mass. On the magnification vi ws, the Micrometastatic disease is repor ted in the sentinel l ymph node
calcifications are pleomorphic and there are associated linear forms [pT2, pN1mi(sn) (i), pMX, Stage IIB].
consistent with ductal carcinoma in situ with central necrosis, Given the incidence of multifocal, multicentric, and bilateral
likely high-nuclear-grade. Biopsies of the mass and calcification lesions, thorough evaluation of patients w ho are lik ely to have a
are indicated because if these confi m the suspected diagnoses, this
malignancy is critical preoperatively. The mammogram needs to be With appropriate imaging protocols, magnetic resonance imaging
reviewed carefully. Complete ultrasound evaluations of the breasts also makes the e valuation of inter nal mammary, axillary, supra-
and ipsilateral axilla, as w ell as magnetic resonance imaging, are clavicular, and neck lymph nodes possible for our patients.
also helpful in e valuating patients diagnosed with breast cancer .
PATIENT 4
views.
view, a low-density nodule is suspected inferiorly on the left medi-

What do you think? Is this a normal study, or is there
olateral oblique view. If the y are a vailable, prior films ould be
a potential abnormality? helpful in assessing whether this finding is n w, stable, or decreas-
ing in size. If prior films are not vailable or this represents a ne w
A lucent-centered, benign-type calcification is present in the righ
or enlarging mass, additional evaluation is indicated.
breast medially. In reviewing these images systematically, a poten-
tial abnormality is noted mediall y in the left craniocaudal (CC)
view. Based on the expected location of this abnormality on the CC
D
Figure 4.4. (Continued) Craniocaudal (C) and mediolateral oblique (D), spot compression views.
mammographic findings, this mass requires biops . In planning the

What do you think now, and with what level of certainty
biopsy, an ultrasound is done because, if the lesion is identified o
can you make a recommendation? ultrasound, ultrasound guidance can be used to do the biopsy. If the
mass is not identified son graphically, a stereotacticall y guided
Did you notice the finge print superimposed on the mass in the
biopsy can be done.
craniocaudal spot compression view? This is a plus-density artifact
that reflects improper film handling after the fil as exposed but
be considered.
before processing. An oval mass with indistinct and spiculated
margins is confi med on the spot compression views. Based on the
E Figure 4.4. (Continued ) Ultrasound image, antiradial (ARAD) projection

(E), at the eight o’clock position, 4 cm from the left nipple.
from the left nipple (F ig. 4.4O). A 0.8-cm, well-differentiated inva-

Based on the mammographic and sonographic findings,
sive ductal carcinoma not otherwise specified is repo ted following
what will you accept as a diagnosis for this mass? the lumpectomy. No metastatic disease is identified in t o excised
sentinel lymph nodes [pT1b, pN0, pMX; Stage I].
A hypoechoic mass is imaged at the eight o’clock position, 4 cm
Correlation is critically important. For clinical findings, does hat
from the left nipple. Using ultrasound guidance, a biopsy of this
is seen mammographically correlate with what the patient or the cli-
mass is done. F ibrocystic changes are repor ted histologically.
nician is describing? In this situation, talking directl y to the patient
What do you think? What would you recommend for this patient?
while doing a physical examination and the ultrasound study can pro-
The imaging and pathology findings are not con ruent. Given the
vide the needed correlation. Specifical y, ask the patient to show you
mammographic features of this mass, the likelihood of malignancy
the location of w hat she is feeling. F or mammographic findings, i
is high and a benign diagnosis on the cores is not acceptable.
what is seen on the ultrasound the same thing as what is on the mam-
In assessing this situation and prob lem solving in general, it is
mogram? If I am doing an ultrasound for a mammographic finding,
helpful to go back to basics. The pathologist should be ask ed if
walk into the ultrasound room with an e xpected clock position in
additional sectioning of the cores can be done, because sometimes
mind and an estimated distance from the nipple. This is my starting
the lesion is deep in the cores and it is possib le that the lesion has
point for the physical examination and where I place the transducer .
not yet been examined histologically. If all available tissue has been
After I have evaluated this area fully, I scan the remainder of the quad-
sectioned and e xamined, the mammo graphic and ultrasound
rant or the breast as needed. For findings on magnetic resonance imag
images should be re viewed. Do the images obtained during the
ing (MRI), is what is seen on the ultrasound the same thing as what is
biopsy confi m adequate positioning of the needle through the
on the MRI? Knowing slice thickness, the distance of the lesion with
mass? Ideally, orthogonal images of the needle are obtained during
respect to the nipple can be estimated and used as the starting point for
the biopsy to document final needle positioning.With small lesions
the ultrasound study. If an imaging-guided biopsy is done, are the
it is particularly important to document that the needle is associated
imaging and histologic findings con ruent? If they are not congruent,
with the mass longitudinally as well as in cross section (F ig. 4.4F
is the problem with the imaging or is there a possibility the lesion has
[I and III] and F ig. 4.4G, I). There are times w hen the needle
not been evaluated histologically (i.e., has all tissue been sectioned?)?
appears to be through the mass longitudinall y, but the needle is
Lastly, following excisional biopsies, is there cor relation
actually just at the edge of the mass (and not in it) when the needle
between clinical and imaging findings and the repo ted histology?
is imaged in cross section (Fig. 4.4F [II] and Fig. 4.4H). Lastly, you
Specimen radiography is used to confi m that a clinicall y occult,
have to ask y ourself: Does what is seen sono graphically correlate
preoperatively (wire) localized lesion is excised and the location of
with the mammographic finding
the lesion in the specimen is mark ed for the patholo gist, thereby
In this patient, the patholo gist has reviewed all available material
assuring that the lesion is examined. However, for patients in whom
and the images during the biopsy document adequate needle posi-
preoperative localization and specimen radio graphy are not done,
tioning. What do you think relative to the cor relation of the lesion
we have had situations in w hich a solid, water-density mass is
seen mammographically with what is imaged on ultrasound? At what
reportedly excised based on palpable findings and a lipoma or othe
clock position would you expect to find the mamm graphic finding
noncongruent lesion is repor ted histologically. In this situation
and at what distance should this lesion be from the nipple?The lesion
either the lesion was not excised or the pathologist did not evaluate
is expected at the 8 o’clock position; ho wever, in measuring back
the lesion of interest in the specimen. In these patients, repeating
from the nipple, this lesion is closer to 8 cm and not 4 cm (F ig.
the mammogram is helpful in deter mining whether the lesion of
4.4J–L) from the nipple. When the patient is scanned at the 8 o’clock
interest has been excised.
position, 8 cm from the nipple, a 9-mm spiculated mass with angular
If we are methodical in our approach and provide the needed cor-
margins and associated shadowing is imaged at this site (F ig. 4.4M,
relation at every step of the process, the clinical breast imager is a
N). This corresponds with the mass seen mammographically and its
critical factor in optimizing patient care. We are in a unique posi-
ultrasound features suggesting a malignant process cor relate closely
tion to provide the needed correlation among clinical, imaging, and
with those seen mammo graphically. Ultrasound guidance is used
histologic findings
preoperatively to localize the mass at the 8 o’clock position, 8 cm
G
F
H I
Figure 4.4. (Continued) Diagram (F) illustrating orthogonal images of needle positioning. Obtaining orthogonal images to document final needle position
ing is particularly critical when sampling small lesions. The needle may appear to be through the lesion (I); ho wever, on the orthogonal image, the needle is
along the edge of the mass (II). Ideally, the needle is surrounded by the lesion on the orthogonal (III) image. Ultrasound images in a different patient demon-
strating the needle through the lesion (G) longitudinally. When the transducer is rotated for the orthogonal image (H), the needle is seen at the edge of the mass
(arrow) and not through it. Ideally, when the transducer is rotated for the orthogonal image (I), the needle is seen within the mass (arrow).
J K
Figure 4.4. (Continued) Diagrams that can be used in conjunction with

the craniocaudal and mediolateral oblique views to estimate the location of
a lesion prior to the ultrasound study . In cor relating mammographic and
ultrasound findings, it is helpful to sta t the ultrasound with an estimate of
the clock location of a lesion and its expected distance from the nipple. On
the mediolateral oblique view/diagram (J), this lesion is “x cm” belo w the
posterior nipple line. On the craniocaudal vie w/diagram (K), this lesion is
medial and posterior in location. The lesion is approximately 8 cm posterior
to the nipple. On the frontal diag ram (L), which simulates the position of
the patient for the ultrasound study, the expected clock position of the lesion
is estimated by drawing a line “x cm” below the posterior nipple line. In this
L patient the lesion should be at 8 o’clock position, 8 cm from the nipple.
M N
Figure 4.4. (Continued) Ultrasound images, radial (RAD) (M) and antiradial (ARAD) (N) projections obtained at the 8 o’clock position, 8 cm from the
left nipple, confi m the location of a mass that cor responds with the mammographic finding. Its son graphic features more closely resemble those of the
mass seen mammographically.
Figure 4.4. (Continued) Single mammographic view (O) obtained fol-

lowing an ultrasound-guided wire localization of the lesion at the 8 o’clock
position, 8 cm from the left nipple.The localization wire is through the mass.
PATIENT 5
Figure 4.5. Diagnostic evaluation in 43-year-old patient presenting with a tender “lump” in the right sub-
areolar area. Craniocaudal (A) and mediolateral oblique (B) views.
What are your observations? of women who breastfeed, and abscess formation affects 1 in 15 of
all women who breastfeed. In this patient population, Staphylococcus
There is increased density in the right subareolar area cor respon- aureus is the most common causati ve agent. P atients with mastitis
ding to the site of concern to the patient. In looking at the technical alone are usuall y treated ef fectively with antibiotics. If an abscess
factors, the right breast is less compressib le and a higher kilovolt- develops, percutaneous drainage can be helpful, and surgical drainage
age and milliamperage were needed for e xposure when compared may be required for some patients. These patients are usually treated
with the left breast. Ph ysical examination and an ultrasound are by their obstetricians and are not usually referred for imaging.
indicated for further evaluation. The second group of patients to consider in terms of breast infec-
On physical examination, erythema and peau d’orange changes tions is those with recur ring subareolar abscess formation unre-
are noted in the periareolar area. Significant tende ness is elicited lated to nipple piercing or nipple rings. These patients are nonlac-
with gentle compression. A mass is palpated in the right subareolar tating, premenopausal w omen, most with a histor y of hea vy
area. Sonographically, a mass with posterior acoustic enhancement smoking. As seen in this patient, man y of these patients de velop
is imaged in the subareolar area, cor responding to the palpab le periareolar fistulas spontaneous y (Zuska’s disease). Squamous
finding (Fig. 4.5C). Based on the clinical presentation and the metaplasia involving the subareolar ducts is seen histolo gically in
imaging findings, an ongoing inflammat y process is suspected. these patients, and it is postulated that this process leads to obstruc-
The patient is started on antibiotics. tion of the ducts, with inspissation of secretions, duct wall erosion,
The patient returns within 72 hours, describing progressive symp- and the development of periductal mastitis and abscess for mation.
toms and purulent fluid draining from the periareolar area. On p ys- Antibiotic therapy alone is not usuall y effective in these patients.
ical examination, erythema and peau d’orange changes are again Although some have advocated percutaneous drainage, this also is
noted, but these are now much more extensive and there is now a pro- not always effective, and wide surgical excision is required. Even in
tuberant mass extending into the upper inner quadrant of the right the patients who undergo surgical drainage, however, there is a high
breast. The overlying skin is thinned and there is a fistula drainin incidence of recurrence. With recurrent episodes, the nipple begins
purulent fluid at the areolar ma gin at the 1 o’clock position (F ig. to flatten and some patients d velop horizontal inversion centrally
4.5D). On ultrasound, the abscess has increased in size (F ig. 4.5E). in the nipple (Fig. 4.5F, G). Bilateral abscess formation is seen in as
Given the rapid progression of symptoms, the formation of a fistula many as a quarter of these patients, either simultaneously or at dif-
and the subareolar location of this abscess, the patient is transfer red ferent times. A mixture of aerobic and anaerobic organisms is often
to the hospital for consultation and surgical drainage. cultured in these patients. It has been repor ted that these patients
have a higher incidence of acne, hidradenitis suppurati va, and per-
ineal inclusion cysts.
When considering mastitis and abscess formation, Lastly, peripheral mastitis or abscess formation can be seen
what groups of patients should you consider? unrelated to pregnancy and lactation. Rarely, some of these
patients are diabetic; most of the w omen in this g roup, however,
Three different patient populations can be considered relative to mas- are otherwise health y, with no identifia le source of infection.
titis and breast abscess formation. Most commonly, we associate these These patients respond w ell to antibiotic therap y and infection
inflammato y conditions with women who are breastfeeding: This is usually does not recur. They are also unlikely to present with bilat-
puerperal mastitis. Reportedly, mastitis occurs in approximately 2.5% eral findings
C Figure 4.5. (Continued) Ultrasound image (C) of the right subareolar area at
the site of the palpable finding
E
D
F G
Figure 4.5. (Continued) Photograph of the breast (D) and ultrasound image (E) of the right subareolar area, 72 hours follo wing (C). Second patient pre-
senting with a tender mass in the right subareolar area. On physical examination (F), there is erythema (long arrows) in the periareolar region laterally. Other
pertinent observations include a periareolar scar (small arrows) and a healed fistula double-headed arrow). This patient has had multiple recurrent episodes
of subareolar abscess formation with prior surgery and fistula fo mation. Also note the horizontal inversion (arrowhead) of the nipple. It is postulated that this
type of nipple inversion is a reflection of periductal fibrosis resulting from rec rent episodes of inflammation. In this patient, the ultrasound xamination
(G) demonstrates a lenticular-shaped complex cystic mass in the subcutaneous tissues of the subareolar area (as though dissecting t hrough the subcutaneous
tissues), a common ultrasound appearance of early subareolar abscess formation.
PATIENT 6
A B
Figure 4.6. Diagnostic evaluation, 54-year-old woman called back for a mass
in the left breast detected on her screening study . Left mediolateral ob lique
(A), photographically coned vie w. Ultrasound images, radial (RAD) (B) and
C antiradial (ARAD) (C) projections corresponding to the area of the mammo-
graphic abnormality at the 7 o’clock position, zone 2 (Z2).
if there is a residual abnor mality postaspiration, I will do a needle

biopsy and obtain tissue for histologic evaluation.
After establishing an approach that allo ws me to adv ance the
A 2-cm, macrolobulated mass, with partially well circumscribed and
needle parallel to the transducer, I clean the skin and use lidocaine
indistinct margins, is seen mammographically. On ultrasound, a well-
to anesthetize the skin. Then, using ultrasound guidance, I inject
circumscribed, irregular mass with posterior acoustic enhancement is
lidocaine into the tissue leading up to, but taking care to not go into,
imaged at the 7 o’clock position, zone 2 (Z2), cor responding to the
the lesion. I use ultrasound guidance for administering the anesthe-
mammographic finding.Although a cyst is suspected, the presence of
sia and for doing the aspiration, even in those patients in whom the
internal echoes and the irregular shape of this mass are such that this
mass is palpable. Commonly, the advancing needle displaces the
cannot be called a simple cyst. A cyst aspiration is undertaken. In dis-
mass, or indents the w all, but does not penetrate into the mass
cussing this with the patient, I tell her that if I do not obtain flui , or
(I think this explains many of the patients who present for evalua- As a routine, I discard aspirated fluid. Intra ystic carcinomas
tion of a palpable mass following attempted aspirations that yielded are rare (0.5% of all carcinomas and 0.1% of cysts), and even
no fluid and et we find a yst corresponding to the palpable find when an intrac ystic carcinoma is present, ne gative cytology is
ing). By visualizing the trajector y of the adv ancing needle, I can obtained in more than half of patients. I submit fluid for ytology
gauge the amount of compression I need to appl y to ef fectively if I obtain b loody fluid foll wing an atraumatic tap, if there is a
immobilize the mass and the amount of controlled pressure I need residual abnormality postaspiration, or if requested by the patient.
to exert with the needle so that the cyst wall is punctured. Once the It has also been recommended that fluid be submitted for ytology
needle is in the mass, I pull the stylet out of the 20G spinal needle, when a repeat aspiration is done in a patient w ho presents with
attach a 10-mL syringe, and aspirate. I w atch on real-time ultra- rapid reaccumulation of fluid. As mentioned previously, in addi-
sound as I aspirate to be sure there is no residual abnor mality tion to submitting aspirated fluid for ytology, when a residual
postaspiration. Also, in some patients, the needle ma y need to be abnormality is seen postaspiration, I do core biopsies through the
redirected (i.e., the tip of the needle put against the c yst wall) dur- residual lesion.
ing the aspiration to be sure that all of the fluid is aspirated. If I d Cysts have a v ariable mammographic appearance. They are
not obtain flui , I may try using an 18G spinal needle, and if I still usually round or o val masses with mar ginal characteristics that
do not obtain flui , or if there is a residual abnor mality postaspira- range from well circumscribed to obscured, to indistinct (partic-
tion, I proceed with core biopsies using the 14G needle. ularly when inflamed). Mural and intra ystic calcifications (mil
In this patient, 8 mL of greenish fluid is aspirated and no residua of calcium) may be present. On ultrasound, simple cysts are well-
abnormality is seen following the aspiration. At this point, I inject circumscribed, anechoic masses with posterior acoustic enhance-
4 mL of air (50% of the aspirated fluid olume) into the cyst cavity, ment and thin edge shado ws. Less common appearances include
because it has been suggested that b y doing this we can lower the the presence of intracystic echoes that during real time are charac-
incidence of cyst recurrence. The air does not hurt the patient, and terized by movement (e.g., “gurgling”), and persistent, nonmovable
if it is helpful in minimizing the likelihood of a recurrence, it can be echoes that sometimes have an S-shaped (yin-yang sign) interf ace
beneficial to the patient. If I am concer ned about the presence of a with the more anechoic portion of the cyst. If the cyst is small and
mural or intracystic abnormality, spot compression magnificatio deep in the breast, posterior acoustic enhancement ma y not be
views of the mass are done following the injection of air in the cyst apparent.
(i.e., a pneumocystogram) to further evaluate the wall of the cyst.
PATIENT 7
under the age of 30 years or those who present during pregnancy
What would you do to evaluate this patient?
or lactation regardless of age. A full mammogram is done only if
When would you obtain a mammogram for a
breast cancer is suspected based on the clinical and ultrasound
20-year-old woman? findings
Correlative physical examination and an ultrasound are our start-
ing point in e valuating focal signs and symptoms in w omen
A Figure 4.7. Diagnostic evaluation, 20-year-old patient presenting with a

“lump” in the left breast. Ultrasound image (A) in the radial projection of the
palpable finding at the 4 o’clock position, left subareolar area
The preaspiration image documents needle placement in the mass

How would you describe the finding, and what is your
(Fig. 4.7B).A little less than 1 mL of serous flui is aspirated. No resid-
differential? What would you recommend next? ual abnormality is seen postaspiration (Fig. 4.7C). On ultrasound, sim-
ple cysts are described as anechoic, well-circumscribed masses with
An oval, well-circumscribed complex cystic mass with posterior posterior acoustic enhancement and thin edge shadows. In some
acoustic enhancement is imaged cor responding to the palpab le patients, however, cysts can be seen with internal echoes that shift in
finding. Although the appearance is some what atypical for a c yst, position as you image them in real time (i.e., gurgling cysts), persistent
this is the main diagnostic consideration. Alternative possibilities echoes that form an abrupt linear or S-shaped (yin-yang sign) interface
include a fibroadenoma, papilloma, and pseudoangiomatous stro with the cystic component of the mass, or high spicular echoes that do
mal hyperplasia. A galactocele, abscess, or posttraumatic or post- not shift in position. Gurgling cysts do not require aspiration unless the
surgical fluid collection ould be considerations in the appropriate patient is symptomatic. Depending on your level of concern, relative to
clinical context. Although a cyst with atypical features is suspected, the latter two types of cysts, aspirations are not absolutely indicated.
aspiration is undertaken.
C
B
Figure 4.7. (Continued) Ultrasound images obtained during the ultrasound-guided aspiration. Preaspiration(B) image, documenting preaspiration needle
positioning in the cyst, and postaspiration (C) image, demonstrating that there is no residual abnormality.
PATIENT 8
Figure 4.8. Screening study, 47-year-old woman. Craniocaudal (A) and mediolateral oblique (B)
views. No prior films are vailable.
What do you think? seeing is not cancer , that cysts do not tur n into cancer, and that
they are common, with man y women developing them at various
A round mass is present in the upper outer quadrant of the left times.
breast. The patient is called back for additional e valuation, which BI-RADS® category 2: benign finding. Annual screening mam-
includes spot compression vie ws and an ultrasound. Dif ferential mography is recommended.
considerations at this point include c yst, fibroadenoma (compl x
fibroadenoma, tubular adenoma), phyllodes, papilloma, pseudoan-
giomatous stromal hyperplasia, adenosis tumor, and focal fibrosis
Depending on the clinical conte xt, sebaceous c yst, galactocele,
postoperative or traumatic fluid collection, and an abscess are als
in the dif ferential. Given the seemingl y circumscribed mar gins,
malignancy is less lik ely; however, invasive ductal carcinoma not
otherwise specifie , medullary, mucinous, or papillar y carcinoma,
or metastatic disease, particularly if the patient has a known malig-
nancy, are additional considerations.
Spot compression vie ws (not sho wn) demonstrate a w ell-cir-
cumscribed mass with no associated calcifications. On ultrasoun ,
a well-circumscribed, anechoic mass with posterior acoustic
enhancement is imaged , consistent with a simple c yst. In an
asymptomatic patient, this requires no additional inter vention or
short-interval follow-up. The patient is reassured that what we are
C D
Figure 4.8. (Continued) Ultrasound images in the radial (RAD) (C, D) projection of the mass in the left breast, at the 2 o’clock position, 3 cm from the
left nipple.
F
Figure 4.8. (Continued) Screening study, 1 year following (A) and (B). Craniocaudal (E) and
mediolateral oblique (F) views.
as long the patient remains asymptomatic, I do not call the

What would you do next?
patient back. If, in re viewing the prior ultrasound there is an y
question about the diagnosis of a c yst (e.g., inter nal echoes,
The mass in the left breast has enlarged. In determining the next
shadowing, or irregular margins), I will call the patient back for
appropriate step, I review the evaluation done the previous year.
a repeat ultrasound.
I focus on the ultrasound study . If, as in this patient, the ultra-
BI-RADS® category 2: benign finding. Annual screening mam-
sound demonstrates a “classic” simple c yst, I do not call the
mography is recommended.
patient back for a repeat e valuation. Cysts fluctuate in size, an
PATIENT 9
Figure 4.9. Diagnostic evaluation, 47-year-old patient presenting

with a “lump” in the right breast. Craniocaudal (A) and mediolateral
B oblique (B) views, metallic BB used to mark location of palpab le
finding.
C
Figure 4.9. (Continued) Spot tangential (C) view of palpable finding
density lesion such that differential considerations include a lymph

node, fat necrosis, hematoma, galactocele, or a fibroadenolipoma
you recommend next? The patient does not recall an y recent trauma, and there is no his-
tory of a recent pregnancy.
A well-circumscribed mass is imaged cor responding to the palpa-
ble finding. On the tangential vi w, this appears to be a mix ed-
D E
Figure 4.9. (Continued) Ultrasound images in the radial (RAD) (D) and antiradial (ARAD) (E) of the palpable finding
persistent abnormality. On inspection of the cores, a central area of

hemorrhagic tissue (i.e., a lesion) is noted , on either side of w hich
recommendation?
fatty tissue is seen. This correlates with what is seen mammograph-
ically: The lesion is surrounded by fat. The appearance of the cores,
On physical examination a discrete, mobile, hard mass is palpated
in conjunction with that of the aspirate, suggests either a hematoma
at the 10 o’clock position, 6 cm from the right nipple. A well-
or fat necrosis. The aspirated fluid is submitted for ytology and the
circumscribed, oval 1-cm mass that is nearl y anechoic with poste-
cores are submitted for histologic evaluation. Predominantly blood
rior acoustic enhancement is imaged corresponding to the palpable
and hemosiderin-laden macrophages are repor ted on the cytology.
finding. Although a cyst is suspected given the presence of internal
Fibroadipose tissue with granulation tissue, necrosis, hemosiderin-
echoes and following a discussion with the patient, an aspiration is
laden macrophages, chronic inflammation, at necrosis, and for-
undertaken.
eign-body giant cells are repor ted on the cores. These findings ar
The mass is atraumatically punctured using a 20G spinal needle
congruent with the clinical and imaging findings and the ross
and grossly bloody fluid is aspirated.Although several attempts are
appearance of the cores. Annual mammography is recommended
made to reposition the needle, no additional fluid is obtained and
for this patient.
residual abnormality persists. Core biopsies are done through the
F G
Figure 4.9. (Continued) Ultrasound image (F) after approximately 0.5 mL of grossly bloody fluid (G) is aspirated.
Figure 4.9. (Continued) Image of one of the core samples (H) demon-
strating hemorrhagic tissue flan ed by fatty tissue.
PATIENT 10
Figure 4.10. Diagnostic evaluation, 47-year-old patient presenting with a “lump” in the right
breast. Craniocaudal (A) and mediolateral oblique (B) views with a metallic BB placed at site of the
palpable finding, right breast
C
Figure 4.10. (Continued) Spot compression view (C) of the palpable finding
A round mass with partially well circumscribed margins is pres- traumatic fluid collection, and an abscess are also in the di feren-
ent in the right breast, corresponding to the site of clinical concern. tial. Given the seemingl y circumscribed mar gins, malignancy is
The differential considerations for the mammo graphic findings i less likely; however, invasive ductal carcinoma not otherwise spec-
this patient include cyst, fibroadenoma (tubular adenoma, compl x ifie , medullary, mucinous, or papillar y carcinoma, or metastatic
fibroadenoma), papillary lesion, focal fibrosis, pseudoangiomatou disease, particularly if the patient has a kno wn malignancy, are
stromal hyperplasia (PASH), adenosis tumor, and phyllodes tumor. additional considerations. An ultrasound is indicated for fur ther
Depending on the clinical conte xt, galactocele, postoperati ve or evaluation.
D E
Figure 4.10. (Continued) Ultrasound images, radial (RAD) (D) and antiradial (ARAD) (E) projections of the palpable finding at the 6 o’clock positio
of the right breast, 2 cm from the nipple.
abnormality is seen postaspiration. The fluid is submitted for yto-

logic evaluation. Abundant red blood cells in a background of acel-
recommendation?
lular debris are reported on the thin prep, and the cell b lock mate-
rial is submitted for cytology. No malignant cells are identified
There is no histor y of a recent pre gnancy, trauma, surgery, or sig-
The fluid reaccumulated in a matter of dys. This, in combination
nificant tenderness. On ph ysical examination, a hard but mobile
with the bloody fluid obtained during the initial aspiration, suggest
mass is palpated at the 6 o’clock position, 2 cm from the right nip-
that further action is indicated. An excisional biopsy is performed,
ple. A well-circumscribed mass with internal echoes and posterior
and an inter mediate-grade, intracystic papillary carcinoma con-
acoustic enhancement is imaged cor responding to the palpab le
fined within a fibrous capsule (i.e., ductal carcinoma in situ) i
finding. Although a cyst is suspected, the echoes did not change in
reported on the e xcisional biopsy [pTis, pN0(sn), pMX; Stage 0].
position during the ultrasound study and so an aspiration is under-
There is no e vidence of in vasion. Atypical ductal h yperplasia is
taken. The mass is easily and atraumatically punctured, and approx-
reported in the surrounding tissue.
imately 8 mL of g rossly bloody fluid is aspirated. No residua
F G
Figure 4.10. (Continued) Ultrasound images, radial (RAD) (D) and antiradial (ARAD) (E) projections of the palpable finding at the 6 o’clock positio
of the right breast, 2 cm from the nipple. Ultrasound images (F, G) obtained during aspiration.
Intracystic papillary carcinomas are rare, but they should be sus-

pected if bloody fluid is aspirated foll wing an atraumatic tap, if
there is a residual abnor mality following the aspiration, or if flui
reaccumulates rapidly. It is also important to emphasize that cytol-
ogy is ne gative in a significant number 50%) of patients with
intracystic carcinomas, so if there is a mural or intrac ystic compo-
nent, core biopsies through these areas ma y be useful in establish-
ing the correct diagnosis.
H
Figure 4.10. Ultrasound image (H), approximately 72 hours follo wing
the aspiration.
PATIENT 11
B
Figure 4.11. Diagnostic evaluation, 58-year-old patient who presents describing nipple dischar ge on the right. Craniocaudal
(A) and 90-degree lateral (B) magnification views of the right breast follo wing a ducto gram. Magnification vi w,
craniocaudal projection, right breast.
focused on the nipple and magnification of the nipple are helpful.

How should patients presenting with nipple discharge
start by examining the surface of the nipple for an y crusting or a
be evaluated? What do you think of this ductogram?
duct opening that appears er ythematous or more patulous than the
others. These may be indicators of a duct opening that needs to be
For patients presenting with nipple discharge, a full mammogram is
cannulated for ductography. I next use an alcohol wipe to clean the
done (images not shown for this patient), history is obtained, and a
surface of the nipple (this clears any keratin plugs that may be par-
physical examination is done. If it is determined that the nipple dis-
tially or completely occluding the duct opening) and I examine the
charge is spontaneous, a ductogram is done. In this patient, the can-
breast for any palpable mass. In doing the exam, I check to see if I
nulated duct is dilated (arbitrarily, we use the cannula as an internal
am able to elicit dischar ge. In man y patients with an intraductal
reference for duct size; nor mal ducts are one to three cannulas in
lesion, it is possib le to identify the trigger point described b y
diameter) and there are tw o lesions in the duct. The anterior-most
Haagensen. When you apply pressure over the trigger point, dis-
lesion is a filling defect; the second lesion is obst ucting a side
charge is elicited. As you move away from the trigger point, the dis-
branch of the involved duct (Fig. 4.11C, arrows). These are likely to
charge stops. In man y patients with an intraductal lesion, the dis-
be papillomas, but e xcisional biopsy is recommended. Excisional
charge is projectile (shoots out at you and can hit you in the eyes if
biopsy in this patient confi ms the presence of intraductal papillo-
you are not careful) and copious.
mas with no atypia or other associated proliferative changes.
If the patient provides a history of spontaneous nipple discharge,
Ultrasound is sometimes used to e valuate women with nipple
and single-duct dischar ge is elicited on ph ysical examination, a
discharge. It is impor tant to recognize that this is useful w hen the
ductogram is undertaken even in women with hem-occult-negative
lesion or lesions are close to the nipple and in a dilated duct.
discharge. If fluid is di ficult to obtain, and it originates from mul-
However, this is not always the situation. Intraductal lesions can be
tiple duct openings bilaterally, ductography is not indicated. We do
found several centimeters away from the nipple in nondilated ducts
not routinely submit nipple dischar ge for cytology, and we do not
and therefore are not always identified y ultrasound.
routinely do hem-occult testing. A negative cytology report does
Ductography can provide information relative to the course of the
not exclude significant pathol gy, however, and if atypical cells are
abnormal duct, the number and location of lesions, and the likely eti-
described, the issue of estab lishing the presence and location of a
ology of the lesions. It is not appropriate to assume, as man y sur-
lesion in the duct remains.
geons do, that lesions causing nipple discharge are in the subareolar
There is a misconception that onl y bloody nipple dischar ge is
area or that the ducts containing the lesions are dilated and therefore
significant. On the contrar y, clear or serous hem–occult-ne gative
identifia le intraoperatively. Even if the abnor mal duct is identifi
discharge may reflect the presence of under ying ductal carcinoma
able at the time of sur gery, the number and location of potential
in situ, so if nipple discharge is spontaneous, it warrants additional
lesions cannot be estab lished reliably through visual inspection
evaluation. Although ductography is not a perfect test and it is
intraoperatively. When patients are tak en to the operating room
associated with a 15% f alse negative rate, ducto graphy can be
because of discharge but in the absence of preoperati ve evaluation,
helpful in identifying the presence of one or multiple intraductal
blind excisions are done, with no assurance that the cause of the dis-
lesions, the location and course of the duct containing the lesions,
charge has been excised and evaluated histologically. Following duct
and the extent of the lesion. It seems to be a more helpful study
excision, the dischar ge is usuall y eliminated. The patient ma y be
than doing cytology and blind surgical excisions that can poten-
relieved, but what have we accomplished if the underl ying lesion,
tially cut through tumor or leave a lesion in the breast while elimi-
possibly a ductal carcinoma in situ, has not been excised?
nating the presenting symptom. Duct openings are closely apposed
on the surface of the nipple, so a 15% f alse negative rate for duc-
tography is not surprising. If a normal ductogram is obtained in a
What information is useful in evaluating women who
patient with a history and physical examination that is highly sug-
present with nipple discharge?
gestive of an intraductal lesion, I assume the normal ductogram is
a false negative study and ask the patient to return in 1 week for a
Obtaining a good histor y is a helpful star ting point in e valuating
repeat study.
patients who present describing nipple dischar ge. We ask the
patient: “How did you notice the dischar ge?” Invariably, patients
with significant nipple discha ge provide one, or all, of three
descriptions: They notice dark brown spots in the cup of their bra, How is a ductogram done?
dark spots on their night clothes, or the y have just gotten out of a
hot bath or shower, dried their breasts, and notice fluid coming fro The secreting duct opening is cannulated using a blunt-tipped 30G
their nipple. This is spontaneous nipple discharge, and regardless of straight sialography needle. As a starting point, 0.2 mL of contrast
its appearance (e.g., clear, serous hem-occult-negative or bloody), is injected into the duct. The cannula is left in the duct and taped
requires further evaluation. It should be contrasted with e xpressed onto the breast. Craniocaudal and 90-de gree lateral magnificatio
nipple discharge that is physiologic in etiology and does not usually views of the breast are obtained. The initial amount of contrast
require additional evaluation. A variable amount of fluid is found i injected is small, so that the subareolar por tion of the duct can be
normal ducts, so nipple dischar ge can be obtained from multiple evaluated. If more contrast is injected at the onset, the density of the
duct openings, bilaterall y, in most w omen following vigorous contrast may mask small lesions close to the nipple, resulting in a
breast and nipple manipulation. false negative study. By leaving the cannula in the duct, additional
The next step in evaluating women with nipple discharge is phys- contrast material can be injected as needed.
ical examination. A bright source of light (e.g., a halo gen lamp)
erative ductograms. A methylene blue contrast (1:1) combination

What are the common causes of spontaneous nipple
is injected into the duct on the day of surgery. The contrast allows
discharge, and what are the more common findings on us to verify that we have cannulated the previously evaluated duct
ductography? (i.e., the duct with the intraductal lesions), and the methylene blue
stains the duct for the surgeon and pathologist. Having the ability
Papillomas, fibro ystic changes, duct ectasia, and breast cancer to identify the duct stained in blue intraoperatively can effectively
(usually ductal carcinoma in situ) are the more common causes of limit the e xcision to the abnor mal duct. Of equal impor tance is
spontaneous nipple dischar ge. Findings on ducto graphy include facilitating identification of the abno mal duct for the pathologist,
one or multiple filling defects, duct obst uction, wall irregularity, because even if the duct is dilated intraoperati vely, it collapses as
displacement of the duct, extravasation, and duct dilatation. the fluid drains out after xcision. The methylene blue is used to
identify the duct grossly and direct the dissection for identificatio
What can be done preoperatively to assure excision of of the lesion. Rarel y, if the intraductal lesion(s) is peripheral in
location (i.e., not in the subareolar area) or if it is in a small branch
the abnormal duct, and how can we facilitate the
of the main duct, the ducto gram is done the da y of surgery and
histologic evaluation of intraductal lesions? used to guide a mammo graphically guided preoperati ve wire
localization.
In addition to doing diagnostic ducto grams to establish the pres-
ence, location, and extent of intraductal lesion, we also do preop-
Figure 4.11. (Continued ) Two intraductal lesions ( arrows) are present

C (C) in a dilated duct. Excisional biopsy confi ms the preoperative diagnosis
of papillomas.
PATIENT 12
B
Figure 4.12. Diagnostic evaluation, 61-year-old patient presenting with nipple dischar ge
on the left. Craniocaudal (A) and mediolateral oblique (B) views.
D
Figure 4.12. (Continued) Spot compression views of the left subareolar area, craniocaudal (C) and medio-
lateral oblique (D) views.
The patient describes a se veral-month history of dark bro wn

spots on her bra cup and dripping from her left nipple after hot
showers. On physical examination, there is some crusting involving
A predominantly fatty pattern is present, with axillary lymph nodes
one of the duct openings on the left nipple.An alcohol wipe is used
noted bilaterally. Scattered round calcifications, a terial calcifica
to clear the crusting. With gentle compression of the left subareolar
tions, and a 1-cm mass with relati vely well circumscribed margins
area, discharge is elicited easil y from the opening that originall y
and a round calcification are noted on the subareolar spot compres
had the crusting. This duct is cannulated and 0.2 mL of contrast is
sion views. Given the described nipple dischar ge, a more detailed
injected.
history of the discharge and a physical examination are indicated.
E G
Figure 4.12. Ductogram, magnification vi ws of the subareolar area: 90-de gree lateral (E), 90-degree lateral photographically coned (F), and cranio-
caudal (G) views, left breast.
trast extravasation. The duct openings are closely apposed on the

What do you think? What is your differential, and what
surface of the nipple. If too much discharge is elicited when try-
would you recommend? ing to identify the duct opening, an adjacent opening ma y be
flooded with fluid and inad ertently cannulated. If the histor y
The opacified duct is minimal y distended. Multiple filling defect
and physical examination are suggestive of an intraductal lesion,
and areas of duct wall irregularity are present (arrows, Fig. 4.12H, I).
a normal ductogram is considered a false negative study and the
The duct leads up to the mass noted in the spot compression views.
patient is asked to return for a repeat ductogram. Because we do
On the craniocaudal view, round, well-defined lucencies consistent
diagnostic and preoperati ve ductograms (repeat ducto gram on
with air bubbles are seen in addition to the filling defects and all
the day of surgery using a methylene blue:contrast combination),
irregularity. Differential considerations for the findings includ
we know that our false negative rate for ductography is approxi-
papilloma(s), ductal carcinoma in situ (DCIS), or fibro ystic
mately 15%.
changes (e.g., hyperplasia, atypical ductal hyperplasia). Given the
In preparing for the ductogram, contrast is drawn into a 3-cc luer
multiplicity of findings in conjunction with the all irregularity,
lock syringe and the contrast is run through the tubing of the sialog-
DCIS is a significant consideration in this patient. Excisiona
raphy needle. Every effort should be made to eliminate air bubbles
biopsy is recommended. A high-nuclear-grade ductal carcinoma in
from the system prior to cannulation. If air bubb les inadvertently
situ is diagnosed at the time of the excisional biopsy [pTis, pN0(sn)
enter the duct system the y are usually easy to distinguish from a
(i), pMX; Stage 0].
lesion. Air bubbles are well define , lucent, and shift in position
between films. Intraductal lesions are characterized y irregular
What are the likely causes of spontaneous nipple contours, and they do not shift in position between films
discharge, and what can be seen on ductography? A small amount (0.2 mL) of contrast is injected initially because
otherwise, small lesions, particularly when close to the nipple, can
Papillomas are the most common cause of spontaneous dischar ge, be masked. Because we leave the cannula in the duct, we are able to
diagnosed in slightly more than 50% of patients w ho present with inject additional contrast as needed to distend the more peripheral
spontaneous nipple discharge. One or multiple filling defects, duc portions of the duct.
obstruction, and wall irregularity are the most common findings o Perforation of a normal duct is rare; it tak es significant pressure
ductography in patients with papillomas. Most ducts that contain and the patient describes a shar p pain when the duct is perforated
papillomas are dilated. and burning as soon as you inject contrast. Adhering to some simple
Fibrocystic changes represent the second most common cause of guidelines during cannulation can pre vent this possible complica-
nipple discharge, reported in appro ximately 35% of patients. tion. After identifying the secreting duct opening, I angle the can-
Filling of cysts with contrast, multiple filling defects, duct obst uc- nula approximately 45 degrees, place the tip at the secreting duct
tion, and a more diffuse wall irregularity than that seen with a papil- opening, and straighten the cannula. It usually “falls” into the duct.
loma are the findings related to fibr ystic changes on a ductogram. If it does not, I gently twirl the cannula between my thumb and index
Distended ducts in close pro ximity to the nipple characterize fingers but do not apply any pressure or try to advance the cannula
duct ectasia; the opacified ducts assume a more no mal caliber forcefully. If I have identified a trigger point, I t y to angle the can-
peripherally in the tissue. No focal intraductal abnormality is iden- nula in the direction of the trigger point. Sometimes, lifting the nip-
tified in patients with duct ectasia ple up so as to “straighten” the duct in the subareolar por tion can
Breast cancer, commonly ductal carcinoma in situ, is diagnosed also be helpful. As I am manipulating the cannula, I repeatedl y ask
in 5% to 15% of patients who present with spontaneous nipple dis- the patient if she is feeling an ything sharp. If the patient describes
charge. In some of these patients, a mass or pleomorphic calcifica any discomfort, I stop and reposition the cannula. Ductography is a
tions may be seen on the mammogram; for many patients, however, painless procedure, so if the patient describes discomfor t it is com-
the mammogram is nor mal. The findings on duct graphy overlap monly an indication that the cannula is not in a duct opening.
with those described for papillomas and include one or multiple Contrast extravasation can be seen in the context of duct perfora-
filling defects, duct obstr uction, wall irregularity, displacement of tion. In this situation, the patient describes a bur ning sensation as
the duct, and contrast extravasation. In general, ducts involved with soon as you attempt to inject contrast, and an amorphous collection
ductal carcinoma in situ are nor mal in caliber or onl y minimally of contrast is seen in the subareolar area. Alternatively, peripheral
distended. In contrast, ducts with associated papillomas are often extravasation can be seen as an amor phous collection of contrast
moderately to significant y distended. Given the inability to distin- surrounding the side branches of nor mal or hypoplastic ducts. In
guish between papillomas and ductal carcinoma in situ on ducto g- this situation, the patient e xperiences no discomfor t as y ou start
raphy, excision is recommended for all patients identified with a injecting the contrast, but she will describe a bur ning sensation
intraductal lesion. after some v olume of contrast has been introduced into the duct
Potential pitfalls on ductography include f alse negative stud- system. Opacification of ymphatic channels is sometimes also seen
ies, air bubbles, masking of lesions, duct perforation, and con- in patients with peripheral contrast extravasation.
Figure 4.12. (Continued) Magnification vi ws of the subareolar area: 90-degree lateral photographically coned (H) and
craniocaudal (I) views, left breast. Multiple filling defects are present in the opacified duct and there are veral areas of
wall irregularity (arrows). A portion of the cannula and multiple air bubbles are also evident on the craniocaudal view.
PATIENT 13
Figure 4.13. Screening mammogram, 54-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.
in patients with positi ve margins postlumpectomy; and in distin-

What do you think? What is indicated next?
guishing tumor recur rence from scar tissue at a prior lumpectom y
site. The use of MRI to screen w omen for breast cancer is indicated
There is dense tissue. A cluster of calcifications is present postero
in patients with dense tissue mammo graphically and a high risk of
laterally in the left breast. Magnification vi ws are indicated for
breast cancer, particularly BRCA1 or -2–positive patients, or those at
further characterization.
least 10 years after chest wall radiation for lymphoma.
Scanning protocols for magnetic resonance imaging of the breast
are still evolving. Bilateral, simultaneous imaging of the breasts is
What is your differential and recommendation? critical in assessing areas of asymmetry, hormonal influence, or dif
fuse change. A dedicated breast coil, at least a 1.5-T magnet, 1-mm
A cluster of pleomor phic calcifications is conf med on the magnifi spatial resolution in all planes, high temporal resolution, a 2-mm
cation views (Fig. 4.13C, D). Fibrocystic changes including hyperpla- slice thickness, subtraction or fat suppression, and biopsy capability
sia, atypical ductal h yperplasia, columnar alteration with prominent are minimal requirements for doing magnetic resonance imaging of
apical snouts and secretions (CAPSS), and sclerosing adenosis as well the breast. As with mammography and ultrasound, meticulous tech-
as fibroadenoma, papilloma, and ductal carcinoma in situ (usual y nique is critical. This includes positioning of the breasts in the coil
low- or inter mediate-nuclear-grade) are in the dif ferential for this with no significant compression as ell as ar m positioning, and
cluster of calcifications. An imaging-guided biopsy is indicated. which vein is used to administer the contrast bolus for the dynamic
BI-RADS category 4: suspicious abnormality, biopsy should be portion of the scan. Lesions are assessed for signal characteristics
considered. A stereotactically guided biopsy is done, and ductal and morphology, using T1- and T2-weighted images and for contrast
carcinoma in situ is reported on the cores. enhancement patterns and kinetic analysis on the dynamic T1 scans
obtained following the administration of contrast.
What would you recommend next? Lesions with high T2 signal intensity are usuall y benign and
include cysts, lymph nodes, and some m yxomatous fibroadenomas
Surgical consultation is indicated. Additionally, we recommend Except for some mucinous carcinomas and necrotic tumors, most
magnetic resonance imaging (MRI) for all of our patients with a malignant lesions are characterized b y low T2 signals. The shape of
diagnosis of breast cancer . This is par ticularly helpful in w omen masses detected on MRI can be described as round, oval, lobulated, or
with dense tissue mammographically. The purpose of the MRI is to irregular, and their margins as smooth, irregular, or spiculated. Margin
better evaluate the extent of disease, including the presence of mul- analysis is best done on the first post-contrast image and is dependen
tifocal or multicentric disease in the ipsilateral breast, and to further on the size of the lesion and spatial resolution. In considering contrast
evaluate the contralateral breast for synchronous lesions. enhancement, lesions ma y demonstrate homo genous or hetero ge-
Irregular and clumped linear enhancement is noted , corresponding neous enhancement, central or rim enhancement, or enhancing inter-
to the area of the patient’s known DCIS in the upper outer quadrant of nal septations. Alternatively, dark internal septations may be seen in a
the left breast (F ig. 4.13E). Additionally, two masses with kinetic mass, reflecting the lack of enhancement. Hom geneous enhance-
curves demonstrating rapid wash-in and wash-out of contrast are pres- ment is more common in benign lesions. Inflammato y cysts and fat
ent in the lo wer outer quadrant of the left breast (F ig. 4.13F). The necrosis may exhibit rim enhancement. Inflammato y cysts, however,
patient is asked to return for ultrasound evaluation of the MRI findings are bright on T2-weighted images, and the use of f at-suppression
A mass with associated shadowing is imaged at the 4:30 o’clock images, in conjunction with mammographic findings and clinical his
position of the left breast, 5 cm from the left nipple.An ultrasound- tory, are helpful in the diagnosis of fat necrosis.
guided biopsy is done and an invasive ductal carcinoma is reported Enhancement can also be seen without the presence of a mass. In
histologically. Given the presence of multicentric disease (synchro- these situations, descriptive terms in the ACR lexicon for lesions
nous lesions in dif ferent quadrants), a mastectom y is recom- detected on MRI include: focal area, linear , ductal (i.e., pointing
mended. On the mastectomy specimen, two foci (1.5 cm and 1.2 cm) toward the nipple and possibly branching), regional (not conform-
of intermediate-grade invasive ductal carcinoma and associated ing to e xpected distribution of a duct), se gmental (triangular
DCIS (cribriform and micropapillary) are identifie , and metastatic enhancement with the apex toward the nipple), multiple regions, or
disease is reported in one of two excised sentinel lymph nodes; an diffuse. Non-mass-like enhancement can be fur ther qualified a
additional positive lymph node is repor ted following the axillar y homogeneous, heterogeneous, stippled/punctate, clumped, reticu-
dissection [pT1c, pN1a, pMX; Stage IIA]. lar/dendritic, symmetric, or asymmetric. Linear enhancement, par-
ticularly when clumped or irregular, is suggestive of DCIS.
What are some of the current indications for magnetic With contrast administration and dynamic imaging, kinetic data
resonance imaging (MRI) of the breasts? can be evaluated. Breast cancers typically enhance rapidly (i.e., “wash
in”), with the enhancement stabilizing (plateau) or gradually decreas-
The role of MRI in breast imaging is evolving, and appropriate indi- ing in signal intensity (i.e., “w ash out”). This is thought to reflec
cations vary, depending on a vailability and e xperience. Described tumor neovascularity and shunting. Nor mal tissue, and most benign
indications include the evaluation of women with an identified malig lesions, demonstrate g radual and continuous contrast enhancement.
nancy, particularly if they have dense tissue mammo graphically. In In describing the signal intensity–time curve, slow, medium, and rapid
these patients, unsuspected multifocal or multicentric disease, or a are used to describe the enhancement pattern of a mass within the firs
breast cancer in the contralateral breast, may be identifie , potentially 2 minutes or when the curve starts to change. The delayed phase of the
altering the management of the patient. Other described uses include curve (after the first 2 minutes or after the cu ve starts to change)
the evaluation of patients with metastatic disease to the axilla with an should be described as persistent if the enhancement continues to
unknown (but presumed) breast primar y, to potentially identify the increase over time, plateau if the signal intensity does not change over
primary; in monitoring the response of a tumor in patients under go- time after the initial increase, or wash-out if the signal intensity
ing neoadjuvant therapy; for assessing the presence of residual tumor decreases after the initial rise.
D
Figure 4.13. (Continued) Craniocaudal (C) and mediolateral oblique (D) double spot compression magnification vi ws of the
left breast.
E F
Figure 4.13. (Continued) Subtraction images (E, F) obtained from precontrast and sequential sagittal T1-weighted images done after the intra venous
bolus administration of gadolinium.
G H
Figure 4.13. (Continued) Ultrasound images, radial (RAD) (G) and antiradial (ARAD) (H) projections.
PATIENT 14
A B
C D
Figure 4.14. Screening mammograms, 50-year-old woman, craniocaudal (A) and mediolateral oblique (B) views, left breast, photographically coned to a
mass in the upper outer quadrant of the left breast. Craniocaudal (C) and mediolateral oblique (D) views, 1 year before (A) and (B), left breast, photographi-
cally coned to the mass in the upper outer quadrant of the left breast.
In this patient, the mass has enlar ged, but the change in size f alls
How would you describe the findings, and why is there
within the acceptable limit. Nevertheless, the next step I take is to call
a metallic clip in the breast? pathology and request a review of the previous biopsy material in the
context of a mass that has increased slightl y in size. The pathologist
An oval, well-circumscribed mass is present in the upper outer confi ms the diagnosis of a fibroadenoma; specifica y, that the histo-
quadrant of the left breast. A metallic clip is present in the mass, logic findings do not suggest the possibility of a p yllodes tumor.
consistent with a prior imaging-guided core biopsy . Metallic clips Annual mammography is recommended for this patient.
are deployed at the time of imaging-guided biopsy procedures BI-RADS® category 2: benign finding
when complete removal of the lesion ma y occur as a result of the In most patients, the diagnosis of a fibroadenoma on core biops
biopsy (e.g., biopsy of a cluster of calcifications or small mas is reliable. In some women, the distinction between fibroadenom
using an 11G vacuum-assisted device). If the lesion is diagnosed as and phyllodes tumor is an issue. In these patients, appropriate man-
a malignancy or high-risk lesion, and it is remo ved in its entirety, agement decisions require placing the imaging findings in th
the clip marks the location of the original lesion so that the tissue proper clinical and pathologic context. Fibroadenomas are common
around the lesion can be localized and e valuated histologically for lesions in younger, premenopausal women. Phyllodes tumors are
residual tumor at the time of the lumpectomy. In reviewing the prior uncommon lesions that occur predominantly in perimenopausal or
biopsy report in this patient, a fibroadenoma is repo ted. The mass postmenopausal women.
is now larger. Fibroadenomas and phyllodes tumors are biphasic (fibroepithe
lial) lesions, arising in the lobules and characterized b y proliferat-
ing epithelial and stromal elements. It is the cellularity of the
What is your recommendation at this point? Because stroma, not the appearance of the epithelial elements, that is used to
the mass is enlarging, is an excisional biopsy distinguish between these lesions. In young women, fibroadenoma
indicated? may be characterized as having a cellular stroma. As estrogen lev-
els decrease with adv ancing age, epithelial elements and stromal
The original diagnosis of a fibroadenoma is con ruent for a well-cir- cellularity in fibroadenomas no mally decrease and h yalinization
cumscribed oval mass seen mammo graphically. In premenopausal (i.e., fibrosis) increases.When fibroadenomas are described as “cel
women, fibroadenomas can enla ge, and a change in size alone does lular,” or when the descriptive term “hypercellular stroma” is used
not constitute an indication for excisional biopsy. It has been reported relative to a fibroadenoma, pa ticularly if it is an older , peri-
that volume growth rates of 16% per month in w omen under the menopausal or postmenopausal patient, a direct discussion with the
age of 50 years, and 13% per month in those over the age of 50 years, pathologist regarding the possibility of phyllodes tumor is helpful.
or up to a 20% mean change in dimension in a 6-month inter val, If the distinction cannot be made reliab ly based on the core sam-
regardless of age, are acceptable, and the patient can be followed. ples, excisional biopsy is recommended.
PATIENT 15
A B
tion, is noted. Additionally, there is a round , well-circumscribed

mass in the lower outer quadrant of the left breast. Prior films ould
be helpful in determining the next appropriate step.
Dense glandular tissue with se veral coarse calcifications, possi ly
reflecting fibroadenomas unde going hyalinization and calcifica
C D
E F
Figure 4.15. (Continued ) Craniocaudal (C) and mediolateral oblique (D) views, left breast, 1 year prior to images shown in (A) and (B). Craniocaudal
(E) and mediolateral (F) views, left breast, 2 years prior to images shown in (A) and (B).
G H
Figure 4.15. (Continued) Ultrasound images, radial (RAD) (G) and antiradial (ARAD) (H), 1 year ago, at the time of (C) and (D).
What do you think? women who present with fibroadenomas. P yllodes tumors com-
monly present as a single, w ell-circumscribed, hard mass; rarel y,
The solid, well-circumscribed mass in the left breast is enlarging. A patients may present with multiple phyllodes tumors in one or both
fibroadenoma was reported on core samples obtained following an breasts. These tumors develop from lobules, and their resemblance
ultrasound-guided biopsy done 1 y ear ago. There is no histor y of to fibroadenomas has led some to suggest that th y arise from pre-
hormone replacement therapy. What do you think? Are the clinical, existing fibroadenomas. Alternatively, some ha ve postulated that
imaging, and histologic findings con ruent? Given the most recent they arise de novo.
mammogram (Fig. 4.15A, B), what is your main concern, and what Histologically, phyllodes tumors are characterized by the presence
would you recommend at this time? of clefts or c ystic spaces lined b y epithelial cells and a cellular
The diagnosis of a fibroadenoma is a con ruent diagnosis for a stroma. The epithelial elements in these lesions are normal and simi-
round, well-circumscribed solid mass, particularly in younger, pre- lar to those seen in fibroadenomas. It is the appearance of the strom
menopausal patients. In such a patient, an increase in the size of a that is used to distinguish ph yllodes tumors from fibroadenomas
fibroadenoma diagnosed with a needle biopsy is not an absolute Attempts have been made to subclassify ph yllodes tumors into
indication for excision unless the change in size is significant. In malignant, benign, and borderline lesions based on their mar gins,
61-year-old woman, however, particularly if she is not on hormone stromal cellularity and o vergrowth, stromal cell atypia, and mitotic
replacement therapy, the diagnosis of a fibroadenoma should b activity. Features that are suggestive of malignancy include the pres-
considered carefully and discussed with the patholo gist directly. ence of infiltrat ve margins, marked stromal cellular o vergrowth,
Fibroadenomas may develop in the earl y postmenopausal period, moderate to mark ed atypia of the stromal cells, and 10 or more
particularly if a patient is started on hormone replacement therapy. mitotic figures per 10 high-p wer fields. eatures of benign tumors
They are not e xpected to de velop and enlar ge years following include expansile margins, moderate stromal cellularity , minimal
menopause in a patient with no histor y of hor mone replacement atypia of the stromal cells, and 0 to 4 mitoses per 10 high-po wer
therapy. The pathologist should be asked specifical y about the pos- fields. A borderline tumor is described w hen a lesion demonstrates
sibility of a ph yllodes tumor. In this postmenopausal patient, the expansile or infiltrat ve margins, moderate atypia of the stromal cells,
original diagnosis should ha ve been challenged and no w, a y ear and 5 to 9 mitoses per 10 high-po wer fields. Rare y, sarcomatous
later, as you review all available studies and note the pro gressive elements including angiosarcoma, liposarcoma, chondrosarcoma,
change in the size of this mass, an excisional biopsy is indicated. myosarcoma, or osteosarcoma are described in the stroma of ph yl-
A benign phyllodes tumor is diagnosed on the excised tissue. lodes tumors.
It is impor tant to emphasize that fibroadenomas in ounger
women are characterized by the presence of epithelial elements and a
What are phyllodes tumors, and how do they present? stroma that may be described as cellular. As patients age, and estro-
gen levels decrease, the epithelial elements and cellularity of the
Phyllodes tumors are rare, representing between 0.3% and 1% of all stroma decrease, and fibrosis and yalinization of the lesion occurs.
breast tumors. They are biphasic (fibroepithelial) tumors, diag The diagnosis of a “cellular” fibroadenoma is accepta le in young
nosed more commonl y in perimenopausal and postmenopausal women (teens and 20s, earl y 30s), but care should be e xercised in
patients. The median age (45 y ears) of patients with ph yllodes accepting the diagnosis of a “cellular” fibroadenoma, or one charac
tumors is appro ximately 15 y ears higher than the median age of terized as having a “hypercellular stroma,” in perimenopausal and
postmenopausal women. In this latter group of patients, the patholo- recurrence. A hematogenous route of spread is described in patients
gist needs to be asked specifical y about the possibility of a phyllodes with metastatic disease. Consequently, axillary dissections are not
tumor, and if this is a concern, excisional biopsy is appropriate. indicated for patients with ph yllodes tumors. Benign ph yllodes
Local recurrence is the main concern in patients diagnosed with tumors do not usually metastasize, have a lower incidence of local
a phyllodes tumor, but distant metastases and death can occur. Wide recurrence, and the interval to recurrence is longer.
surgical excision is critical in minimizing the lik elihood of local
PATIENT 16
A B
Figure 4.16. Screening study, 64-year-old woman. Left craniocaudal (A) and mediolateral oblique (B) views, photographically coned.
How would you describe the findings? Is this congruent with the imaging findings? At this
point, what is your recommendation for this patient
Two masses are present in the upper outer quadrant of the left breast. and why?
The more superior and lateral of the lesions is characterized b y
microlobulated and irregular margins. The second mass has par tially The mammographic and histologic findings are con ruent. However,
well circumscribed mar gins. Compared with prior studies (not with a sclerosing lesion, atypical ductal h yperplasia, and dissecting
shown), these findings represent a change. Imaging-guided biopsy i mucin reported in the lesion and stroma, an excisional biopsy is rec-
done of the more superior and lateral of the lesions.A sclerosing lesion ommended. Both masses, seen mammo graphically, are excised fol-
with associated atypical ductal hyperplasia and mucin dissecting in the lowing wire localization (F ig. 4.16C, D). An intraductal papilloma
sclerosing lesion and adjacent stroma is reported on the cores. with apocrine atypical ductal hyperplasia and adjacent mucocele-like
tumor were reported for the lesion biopsied previously. An intraduc- the diagnosis of a mucocele-like lesion, or the presence of mucinous
tal papilloma with no atypia is reported for the second excised mass. material dissecting in the stroma on core biopsy samples, should
prompt consideration of an excisional biopsy of the lesion.
What are mucocele-like lesions of the breast, and how

should they be managed following diagnosis on core What imaging findings have been reported for
biopsy? mucocele-like lesions of the breast?
Mucocele-like lesions of the breast are made up of multiple c ysts or In screening programs, these lesions are usually diagnosed on core
dilated ducts containing mucinous material that is e xtruded into the biopsies done for indeter minate or suspicious microcalcifications
surrounding stroma. The epithelial cells lining these cysts or ducts are some of the described calcifications are coarse and ggshell-
uniformly flat or cuboidal to columnar in appearance. Although they shaped. Masses with mar gins ranging from w ell circumscribed to
were initially described as benign lesions, there are now reports in the indistinct, with or without associated calcifications, h ve also been
literature of associated atypical ductal h yperplasia, ductal carcinoma reported. On ultrasound, cysts with noncalcified or calcified mur
in situ (DCIS), or invasive carcinoma with some of these lesions. nodules, hypoechoic masses characterized b y low-level internal
The associated DCIS is usuall y micropapillary or cribriform type, echoes, or tubular structures with low-level internal echoes may be
and the invasive lesion is usually mucinous carcinoma. Consequently, seen in these patients.
C D
Figure 4.16. (Continued) Ninety-degree lateral (C) view documenting final wire positioning foll wing an ultrasound-guided wire localization of both
lesions [arrows in (D)] in the upper outer quadrant of the left breast.
PATIENT 17
(B) views.
What do you think?
A potential mass is described in the left breast. If no prior films ar

available, or if this finding represents an inteval change, the patient
should be called back for spot compression vie ws and possibly an
ultrasound.
Figure 4.17. (Continued ) Craniocaudal (C) and mediolateral ob lique (D) spot compression
views, left breast.
fibroadenoma (complex fibroadenoma, tubular adenoma), papil

What do you think now, and what would you
loma, focal fibrosis, pseudoangiomatous stromal yperplasia, papil-
recommend next?
loma, adenosis tumor, phyllodes tumor, and g ranular cell tumor.
At what clock position would you place the ultrasound Depending on history and clinical findings, an inflammat y process,
transducer to find this mass? posttraumatic/postsurgical fluid collection, and a galactocele migh
also be included in the differential. Malignant considerations include
A mass is confi med on the spot compression vie ws. Although the invasive ductal not otherwise specifie , medullary carcinoma, or
margins are obscured on the craniocaudal projection, they are better metastatic disease. Although they are less lik ely given the patient’s
seen and appear partially well circumscribed on the oblique projection. age, mucinous and papillary carcinomas are also in the differential.
Benign considerations in a 42-y ear-old woman include c yst,
Figure 4.17. (Continued) Ultrasound images, radial (RAD) (E) and antiradial (ARAD) (F) projections corresponding to the area of mammo graphic con-
cern, 6 ’clock position, 2 cm from the left nipple.
What do you think based on the ultrasound images, Is this histology concordant with the imaging findings?
and what is your recommendation? What would you recommend next, and why?
On ultrasound, a hypoechoic oval mass is imaged at the 6 o’clock Pleomorphic calcifications with roun , punctate, and amor phous
position, 2 cm from the left nipple, cor responding to the mammo- forms are the most common mammo graphic finding reflecting t
graphic finding. The margins are not w ell defined and there is n presence of atypical ductal hyperplasia (ADH) and ductal carcinoma
posterior acoustic enhancement; although y ou may be tempted to in situ (DCIS). Rarely, ADH and DCIS can present as parench ymal
call this a c yst, it does not fulfill the diagnostic criteria for a yst asymmetry, distortion, or a mass with w ell-circumscribed, often
and therefore further evaluation is indicated. macrolobulated margins that may be further characterized as indis-
tinct and sometimes spiculated. So the diagnosis of ADH in this
patient with a mass is concordant. However, depending on whether a
How would you approach this patient’s evaluation? 14G automated spring-loaded or an 11G v acuum-assisted device is
used for sampling, ADH is upgraded to DCIS or invasive ductal car-
For patients in w hom a c yst is a possibility , I approach their cinoma on excision in as many as 56% and 27% of patients, respec-
interventional procedures in a stepwise manner . The first step tively. Consequently, excisional biopsy is the appropriate manage-
after injecting lidocaine in the skin and e xpected needle course, ment of patients diagnosed with ADH on core biopsy, regardless of
is to attempt an aspiration. If no fluid is obtaine , or a residual the finding (e.g., calcifications, mass, or dist tion).
abnormality is noted follo wing aspiration, I do core biopsies In this patient, an e xcisional biopsy is done follo wing an ultra-
through the mass. In this patient, no fluid is aspirated and atypi sound-guided preoperative wire localization of the mass in the left
cal ductal hyperplasia (ADH), apocrine type, is repor ted on the breast. A 1.1-cm ductal carcinoma in situ, apocrine type, is diag-
core biopsies. nosed in the excised tissue [pTis, pNX, PMX; Stage 0].
PATIENT 18
A B
Figure 4.18. Diagnostic evaluation, 72-year-old patient called back for evaluation of calcifications detected in the left breast on her screening mamm gram.
Craniocaudal (A) and mediolateral oblique (B) double spot compression magnification vi ws, left breast.
How would you describe the findings? views are obtained after a clip is deplo yed to document the location
of the clip immediately following the biopsy. In this patient, a 14G
A cluster of round, punctate, and amor phous calcifications is con needle in a spring-loaded de vice is used for the biopsy . Complete
fi med on the doub le spot compression magnification vi ws. No removal of the lesion is not expected, so no clip is deployed. Atypical
linear forms, linear orientation, or change in configuration of th ductal hyperplasia with associated microcalcifications arising in
calcifications (i.e., no milk of calcium) is noted on the magnifica background of columnar alteration with prominent apical snouts and
tion views. Fibrocystic changes including h yperplasia, atypical secretions (CAPSS) is reported on the core biopsy.
ductal hyperplasia, columnar alteration with prominent apical
snouts and secretions (CAPSS), and sclerosing adenosis, as well as
fibroadenoma, papilloma, and ductal carcinoma in situ (usuall y What is indicated next?
low- or intermediate-nuclear-grade) are in the dif ferential for this
cluster of calcifications. Biopsy is indicated. A diagnosis of atypical ductal hyperplasia on core biopsy requires
BI-RADS® 4: suspicious abnormality, biopsy should be considered. excisional biopsy. This is done follo wing preoperative wire local-
Stereotactically guided core biopsies are done on this patient. ization of the calcifications in the left breast
Depending on the size of the lesion, the needle used (e.g., 14G, 11G, The calcifications are conf med to be in the specimen (F ig.
8G), the number of cores tak en, and the device used for the biopsy 4.18C). Based on this radiograph, the location of the calcifications i
(e.g., vacuum-assisted or wire bask et), the lesion ma y actually be marked for the pathologist. Residual atypical ductal hyperplasia aris-
completely “excised” during the biopsy . If this is a possibility , a ing in a backg round of columnar alteration with prominent apical
metallic clip needs to be deployed at the time of the biopsy so that the snouts and secretions (CAPSS) with associated microcalcifications i
location of the original lesion is mark ed. If a malignancy or a high- reported on the excised tissue. The pathologist comments that “The
risk lesion is diagnosed, the clip deployed at the time of the imaging- area of CAPSS is par tially involved with a monotonous lo w-grade
guided biopsy can be used to localize the area for e xcision and fur- cell population which is insufficient in extent for a diagnosis of low-
ther histological evaluation. Craniocaudal and 90-de gree lateral grade ductal carcinoma in situ.” Atypical ductal hyperplasia (ADH)
is considered a high-risk marker lesion. Patients with ADH have four distinction between ADH and DCIS can be problematic, particularly
to fi e times increased risk for developing breast cancer compared to given the small amounts of tissue submitted follo wing imaging-
the reference population. This risk is increased further in women with guided needle biopsies. There is a need to increase the number and
ADH and a family history of breast cancer. size (e.g., 14G vs. 11G) of the cores and a need to recommend e xci-
A contiguous layer of epithelial cells and an inter mittent basilar sion if ADH is reported following core biopsies.
layer of myoepithelial cells line the basement membrane of normal The complexity of the situation in managing some patients with
ducts and lobules in the breast. Hyperplasia refers to an increase in these processes is fur ther compounded because, although ef forts
the number of cells (usually epithelial, though in some processes it have been made to define and standardize classification schem
is the myoepithelial cells that are hyperplastic) lining the ducts. In for these processes, the diagnosis of h yperplasia, atypical ductal
usual hyperplasia, the number of epithelial cells lining the ducts is hyperplasia, and low-nuclear-grade DCIS remains subjective. Also,
increased and secondary spaces in the ducts are irregular in size and as described in this patient, some of the criteria for DCIS ma y be
shape and commonly elongated or slitlike. In atypical ductal hyper- present, but the changes are insufficient to qualify for the diagnosis.
plasia, the number of cells lining the ducts is increased , and sec- A study by Rosai in 1991 reported that there was no agreement on
ondary spaces of varying sizes and shapes, though somewhat more a diagnosis in 17 borderline cases submitted for review to fi e lead-
rigid and fi ed than those seen in usual h yperplasia, are present in ing breast pathologists, and the diagnoses rendered in some of the
the duct. These proliferative changes in the duct can pro gress to cases ranged from hyperplasia to DCIS.
ductal carcinoma in situ (usually low- or inter mediate-nuclear- This spectrum of disease should be contrasted with DCIS that is
grade), characterized by a monomorphic cell population and rigid characterized by rapid cell proliferation (high th ymidine labeling)
secondary spaces in the duct. Descriptive terms used for these types and central necrosis. These lesions are thought to arise de no vo in
of DCIS include cribriform, micropapillary, and solid. This spec- the duct, without antecedent h yperplasia or atypical h yperplasia.
trum of cellular changes in the duct is not typically associated with Although these are usually high-nuclear-grade cells, some may be
rapid cell proliferation or central necrosis. The calcifications tha intermediate- or low-nuclear-grade. The cells lining these ducts are
develop in association with these proliferati ve processes develop in pleomorphic, do not demonstrate polarization relati ve to the duct
secretions (not in necrotic debris). The resulting calcifications ar lumen, and have multiple nucleoli. Mitotic figures, cell necrosis
typically variable in density (possib ly reflecting the ariably sized and autophagocytosis may be seen in volving the cells lining the
spaces in w hich they develop) and pleomor phic, including round, ducts. In these patients, the malignant cells circumferentiall y nar-
punctate, and in some patients amor phous (tiny calcifications bel w row the duct lumen and there is necrotic debris in the center of the
the resolution obtainable with magnification vi ws in a patient). duct. The calcifications seen mamm graphically develop in
These processes involve the duct in a multifocal manner so that in necrotic debris and consequently are closely apposed to the malig-
some patients you can have hyperplasia next to DCIS, next to another nant cells (i.e., the calcifications are molded y the proliferating
area of hyperplasia, next to ADH, etc. Several studies have reported cells). In targeting this type of proliferative process, when you tar-
the presence of ADH in a peripheral location to areas of DCIS. In get the calcifications ou target the malignant cells. The number
some patients, the proliferative changes have no associated calcifica and size of the cores is not as critical in these patients. If y ou
tions. In other patients, the proliferative changes have associated cal- remove calcifications in our cores, you are likely to have made the
cifications but these are not necessaril y closely associated with the diagnosis of DCIS.
malignant cells. Consequently, when you target these calcification
you may or may not be targeting the malignant cells. Additionally, the
C
Figure 4.18. (Continued) Specimen radiograph (C) of excised tissue.
PATIENT 19
A B
Figure 4.19. Screening study, 69-year-old woman. Right craniocaudal (A) and mediolateral oblique (B) views.
may be linear with possible linear orientation, is noted in the upper

outer quadrant of the breast anteriorl y. Magnification vi ws are
indicated for further characterization.
Several coarse, dystrophic-type calcifications are present in th
right breast. Additionally, a cluster of calcifications, some of hich
Figure 4.19. (Continued) Craniocaudal (C) and mediolateral oblique (D), double spot compression magnifica
tion views, right breast.
The double spot compression magnification vi ws confi m the thymidine labeling rates, central necrosis in the duct, and a shor t
presence of linear calcifications demonstrating a linear orientation intraductal phase. These types of lesions are all thought to progress
The margins of these calcifications are i regular and there are asso- to invasive disease (i.e., obligate invaders), giving rise to poorly dif-
ciated clefts in the calcifications. Ductal carcinoma in situ (DCIS ferentiated invasive ductal carcinomas. Low-nuclear-grade DCIS is
with associated central necrosis (usually high-nuclear-grade) is the not thought to evolve (i.e., is not a precursor) to high-nuclear-grade
primary consideration with calcifications h ving these features. DCIS.
Biopsy is indicated. Pleomorphic calcifications are the most common mammo
graphic finding associated with DCIS. Depending on the under y-
ing process in the duct, the calcifications h ve a variable appear-
What is your recommendation? ance. In the first roup of proliferative processes, the calcification
have been described as developing in secretions. Although they are
BI-RADS® category 4: suspicious abnor mality, biopsy should be pleomorphic and demonstrate variation in density, they are usually
considered. round, punctate, or amor phous. Multiple clusters ma y be seen.
An invasive mammary carcinoma with predominantl y lobular These calcifications m y be associated with h yperplasia, atypical
features and ductal carcinoma in situ, high-nuclear-grade, with cen- ductal hyperplasia, and DCIS (usually a low- or intermediate-grade
tral necrosis is diagnosed on the core samples. A 1.2-cm, grade III, DCIS). It is also important to recognize that these processes may be
invasive ductal carcinoma with associated high-nuclear-grade duc- present in the breast without any associated calcifications.With this
tal carcinoma in situ with central necrosis is diagnosed on the type of proliferative process, we underestimate the extent of disease
lumpectomy specimen. The sentinel l ymph node is ne gative for in nearly 50% of patients. When doing biopsies of this type of cal-
metastatic disease [pT1c, pN0, pMX; Stage I]. cification, it is impor tant to assure adequate sampling b y either
Ductal carcinoma in situ used to be considered a “rare” disease, increasing the number and size of the cores or e ven considering
with only scattered descriptions in the literature re garding its his- excisional biopsy in some patients. Remo ving some of the calcifi
tologic appearance and biologic significance. With the widespread cations in these patients does not assure a cor rect diagnosis, as
use of screening mammo graphy, and our ability to detect and reflected by the high percentage of ADH that is upgraded to DCIS
biopsy microcalcifications, DCIS no w constitutes a signif icant or invasive cancer w hen ADH is e xcised following diagnosis on
proportion of the breast cancer that is diagnosed and treated. core biopsy.
Driven by mammographic findings, our kn wledge and under- When there is central necrosis in the duct reflecting rapid y prolif-
standing of this disease process has been significant y advanced in erating cells, the calcifications are often linear and m y demonstrate
the last two decades. It is now recognized that DCIS is not one dis- a linear orientation. In this type of proliferative process, the calcifica
ease but se veral diseases characterized b y clinical, mammo- tions are intimately associated with the malignant cells; the calcifica
graphic, and biologic heterogeneity. Based on histolo gy, biologic tions are being molded b y the proliferating cells and de velop in the
markers, and associated invasive lesions, we can consider at least necrotic debris. Targeting the calcification in essence ta gets the
two main paths of origins. One g roup of DCIS arises or e volves malignant cells. If calcifications are rem ved in one or two cores, you
through proliferative changes in the duct that include hyperplasia, are likely to have made the diagnosis. Complete workups with opti-
atypical ductal h yperplasia, and ductal carcinoma in situ. These mal magnification vi ws are helpful in these patients, because mam-
proliferative lesions coe xist and are multifocal in the in volved mography is good at estimating the e xtent of the disease. Disease is
duct. They are characterized b y low rates of proliferation, long found where we see the calcifications. In patients with lesions occu
intraductal phases, and not all of the DCIS arising through this pying several centimeters, the use of multiple wires for the preopera-
pathway is thought to progress to invasion. In some patients, these tive localization f acilitates complete remo val of the lesion.
are thought to be precursors for lo w- or intermediate-grade inva- Aggressive pursuit of these types of calcifications is critical becaus
sive ductal carcinomas. of the short intraductal phase of the disease and the almost cer tain,
In contrast, a second group of DCIS develops in the duct without and in some patients rapid , development of invasive disease (often
progressing through h yperplasia and atypical h yperplasia. This poorly differentiated).
type of DCIS is characterized b y rapid cell proliferation with high
PATIENT 20
Figure 4.20. Diagnostic evaluation, 51-year-old patient called back for calcifications detected in he
right breast on the screening study. Double spot compression magnification vi ws, craniocaudal (A) and
mediolateral oblique (B) projections.
How would you describe the findings? monomorphic cell population, and fewer than half of the acini in the
lobular unit are expanded and distorted by the proliferating cells. In
The magnification vi ws confi m the presence of two adjacent clus- LCIS, the acini are filled with a monomo phic cell population and at
ters of calcifications. The calcifications composing the cluster least half of the acini are distended and distorted by the proliferating
demonstrate pleomorphism and variable density; however, there are cells. In some patients the distinction between LCIS and ductal car-
no linear forms and there is no linear orientation. The calcification cinoma in situ (DCIS) ma y be dif ficult for the patholo gist.
do not change significant y in configuration bet een the craniocau- Immunohistochemical staining for E-cadherin, a cell adhesion mol-
dal and oblique projections (i.e., these do not reflect milk of cal ecule, is used in some patients to distinguish lobular lesions that do
cium). Although there are w ell-defined round and o val calcifica not stain from ductal lesions that do stain for E-cadherin.
tions, some of these would fall under the “amorphous” terminology Lobular neoplasia is an uncommon diagnosis, repor ted in 0.5%
currently provided by the ACR lexicon. It is important to recognize to 3.8% of benign breast biopsies. It is diagnosed predominantly in
that these are not reall y amorphous but rather tight clustering of premenopausal women and is characterized as a multicentric and
punctate calcifications that all below the resolution of the magnifi bilateral process. Although there are now reported cases of calcifi
cation we can obtain when imaging a patient. If these are magnifie cations identified in foci of lobular neoplasia, this is the xception.
three or four times, as can be done with a specimen, some of the In most patients, lobular neoplasia is an incidental finding i
seemingly amorphous calcifications can be resol ed into individual, biopsies done for palpab le or mammo graphic findings. Women
tightly clustered punctate calcifications. ibrocystic changes includ- with lobular neoplasia are at increased risk for developing invasive
ing hyperplasia, atypical ductal h yperplasia, columnar alteration ductal or lobular carcinoma within the first 10 to 15 ears following
with prominent apical snouts and secretions (CAPSS), and scleros- the diagnosis. The increased risk reportedly applies to both breasts,
ing adenosis, as well as fibroadenoma, papilloma, and ductal carci though more recently there has been a repor t suggesting that the
noma in situ (usuall y low- or inter mediate-nuclear grade, with no risk is higher in the breast diagnosed with the lobular neoplasia.
central necrosis) are in the differential for these clusters of calcifica It is postulated that lobular neoplasia re gresses following
tions. A biopsy is indicated. menopause and that these processes are mark er lesions for
BI-RADS® category 4: suspicious abnormality, biopsy should increased risk of subsequently developing breast cancer. However,
be considered. unlike DCIS, which is thought to pro gress to invasive disease in
A stereotactically guided core biopsy is done, and fibro ystic some women, the traditional teaching has been that lobular neopla-
changes including sclerosing adenosis, CAPSS with associated sia is not precancerous. It is interesting to note, ho wever, that in
atypia, and atypical lobular h yperplasia are repor ted on the core close to 50% of postmenopausal w omen diagnosed with in vasive
samples. In discussing the findings direct y with the pathologist, he lobular carcinoma, prominent lobular neoplasia is diagnosed in
confi ms that the calcifications are found in sclerosing adenosis an association with the in vasive lesion. This seems to challenge the
CAPSS; the atypical lobular neoplasia is noted incidentally in sur- notion that this is not a precancerous lesion and that it re gresses in
rounding breast tissue, with no associated calcifications all patients. Alternatively, it may be that this lesion recurs in some
patients.
The management of patients with lobular neoplasia diagnosed
At this point, what do you recommend for this patient? incidentally on core biopsy is e volving and remains controversial.
Unfortunately, available studies at this time are limited by the rela-
Given the presence of CAPSS with associated atypia, and inciden- tively low number of patients repor ted and the potential bias b uilt
tally identified atypical lo ular neoplasia, excisional biopsy is rec- into the retrospective nature of the studies. In the past, e xcisional
ommended for this patient. No malignancy is identified on the xci- biopsy was not usually recommended for most of these patients.
sional biopsy, and the patient is returned to annual screening. More recently, some investigators have suggested that e xcision is
Lobular neoplasia is a term used to describe a spectrum of prolif- required if there is an o verlap in the histolo gic features between
erative changes in the acini of lobules that ranges from atypical lob- LCIS and DCIS, if the histolo gic and imaging findings are discor
ular hyperplasia (ALH) to lob ular carcinoma in situ (LCIS). dant (e.g., if lobular neoplasia is all that is repor ted histologically,
Continuous with that of the ducts, a tw o-cell layer above the base- this may be an inadequate e xplanation for the findings promptin
ment membrane normally lines the acini in a lobule. A contiguous the biopsy), or in those patients in w hom the lobular neoplasia
epithelial cell la yer and a basilar , intermittent myoepithelial cell coexists with another high-risk lesion. Alternatively, a g rowing
layer. Hyperplasia, defined as an increase in the number of cells, i number of authors suggest that e xcision should be the recommen-
present when there are three or more cells above the basement mem- dation for this small g roup of patients because available reports in
brane. In both ALH and LCIS, a monomorphic cell population fills the literature describe malignanc y in 0% to 50% of patients in
distends, and distorts the acini in the lobular unit. In ALH, filling o whom excision is recommended following a core biopsy with inci-
the acini is incomplete, other cell types may be intermixed with the dentally noted lobular neoplasia.
PATIENT 21
C D
Figure 4.21. (Continued) Craniocaudal (C) and mediolateral oblique (D) views, right breast.
What do you think? Is this a normal study, or is

additional evaluation indicated?
A possible area of distortion is imaged in the upper outer quadrant

of the right breast. Additional evaluation is indicated.
E F
Figure 4.21. (Continued) Craniocaudal (E) and mediolateral oblique (F) spot compression views, right breast.
ogist reliably distinguish a complex sclerosing lesion from tubular

What do you think, and what is your differential?
carcinomas and sclerosing adenosis? In a patient with distor tion
and spiculation, can we accept the diagnosis of a complex scleros-
The spot compression vie ws confi m the presence of distor tion.
ing lesion after core biopsy? Is the association of complex scleros-
The finding is readi y apparent on the craniocaudal vie w and
ing lesions with other lesions, including atypical ductal hyperplasia
although it is identifia le on the oblique spot compression view, it
(ADH), lobular neoplasia, lo w-nuclear-grade ductal carcinoma in
is less striking. Dif ferential considerations include f at necrosis
situ, and tubular carcinomas, frequent enough to warrant excisional
related to prior surgery or trauma, complex sclerosing lesion, scle-
biopsy in all patients with complex sclerosing lesions? If a complex
rosing adenosis, papilloma, focal fibrosis, an inflammat y process,
sclerosing lesion is suspected based on imaging and clinical find
invasive ductal carcinoma not otherwise specifie , tubular carci-
ings, should an imaging-guided core biopsy be done?
noma, and invasive lobular carcinoma. Rarely, ductal carcinoma in
In most patients, a comple x sclerosing lesion can be diagnosed
situ can present with distortion in the absence of calcifications. O
on core biopsy samples. Rarel y, the distinction among this entity ,
physical examination, no scar is identified at the xpected location
sclerosing adenosis, and tubular carcinomas can be a challenge his-
of the distor tion and no tender ness is elicited with compression.
tologically. Because atypical ductal hyperplasia, lobular neoplasia,
Given the Leborgne sign, which is that on palpation invasive ductal
ductal carcinoma in situ (usuall y low- or inter mediate-grade), or
carcinomas are larger than what is seen on the mammo gram, one
tubular carcinomas are reported in as many as 33% of patients with
would expect this lesion to be palpable, but it is not. On ultrasound,
complex sclerosing lesions, I recommend e xcision of all comple x
no abnormality is seen at the e xpected location of the mammo-
sclerosing lesions. Alternatively, some have suggested that if the
graphic finding. This suggests either a complex sclerosing lesion or
lesion is not associated with ADH, the biopsy included at least 12
an invasive lobular carcinoma. Atypical ductal h yperplasia is
specimens, and the mammographic findings are reconciled with th
reported on core biopsies. Excisional biopsy is recommended , and
histologic findings, no xcision is required.
a complex sclerosing lesion with atypical ductal h yperplasia and
Complex sclerosing lesions can demonstrate f airly distinctive
sclerosing adenosis is reported on the excised tissue.
mammographic, sonographic, and clinical findings. The mammo-
The management of patients with comple x sclerosing lesions
graphic findings for these lesions include disto tion with central
remains controversial. With respect to these lesions, w e need to
1-to 2-mm locules of f at (i.e., no significant central density), lon
consider several related questions. On core samples, can the pathol-
curvilinear spicules, and better visualization in one of the two pro- Based on imaging and clinical features, the likelihood of a complex
jections, commonly the craniocaudal view. Round and punctate cal- sclerosing lesion can be predicted in a high percentage of patients. In
cifications may be seen in as many as 30% to 40% of lesions.These patients in whom I consider the lik elihood of a comple x sclerosing
lesions are not related to a prior biopsy and, although they are occa- lesion to be high, I recommend an e xcisional biopsy and for go the
sionally palpable, most have no associated clinical finding (unli e imaging-guided biopsy. For those patients in w hom a complex scle-
what would be expected for an invasive ductal carcinoma of com- rosing lesion is in the differential but the imaging and clinical finding
parable size). On ultrasound, normal tissue or a subtle area of dis- are not diagnostic, I do an imaging-guided biopsy; if a complex scle-
tortion with some shadowing that is not necessaril y confi med on rosing is reported on the cores, I recommend excisional biopsy.
the orthogonal image may be noted.
PATIENT 22
Figure 4.22. First screening study, 39-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views.
Figure 4.22. (Continued) Mediolateral oblique (C), anterior compression views obtained as part of her screening study.
area of distortion at the posterior edge of the obvious mass in the

Is this a normal or potentially abnormal mammogram?
left breast?
What are the pertinent observations? BI-RADS® category 0: need additional imaging evaluation.
An oval mass is imaged in the upper outer quadrant of the left
breast. Are there any other obser vations? How about a possib le
D E
F G
Figure 4.22. (Continued) Multiple spot compression (D–G) views of the findings in the left breast
considerations for this finding include yst, fibroadenoma (compl x

fibroadenoma, tubular adenoma), ph yllodes tumor, papilloma,
differential? pseudoangiomatous stromal hyperplasia, adenosis tumor, and focal
fibrosis. Depending on the clinical context, galactocele, postopera-
An area of distortion is confi med on the spot compression views tive or traumatic fluid collection, and an abscess are also in the dif
(Fig. 4.22D–F). It is characterized b y the presence of f atty tissue ferential. Invasive ductal carcinoma not otherwise specified an
centrally and long radiating spicules. It is more apparent on the medullary carcinoma are the main considerations in the malignant
craniocaudal view (Fig. 4.22D). Dif ferential considerations category. Mucinous and papillar y carcinoma are less lik ely, given
include postsurgical or traumatic change, comple x sclerosing the patient’s age.
lesion, papilloma, inflammato y change, focal fibrosis, sclerosin On ultrasound, a well-circumscribed mass with a hetero geneous
adenosis, fibromatosis, i vasive ductal carcinoma not otherwise echotexture and associated c ystic areas is imaged cor responding to
specifie , and tubular carcinoma. Rarely, ductal carcinoma in situ the mass seen mammographically (Fig. 4.22H). Biopsy is indicated.
can present with distor tion in the absence of calcif ications. BI-RADS® category 4: suspicious abnor mality, biopsy should
Invasive lobular carcinoma is also in the dif ferential, however, be considered.
given the patient’s age this is less likely. The patient has no history The specimen radiograph is used to confi m excision of the mass
of breast surgery or trauma, and she is otherwise asymptomatic. and adjacent area of distortion (Fig. 4.22I, J). The localizing wire is
Her physical examination in the e xpected location of the area of seen in the specimen between the two lesions. Based on this image,
distortion is nor mal. No abnor mality is identified on ultrasoun the location of the mass and distor tion are marked for the patholo-
corresponding to the area of distortion seen mammographically. A gist. A complex sclerosing lesion with no associated proliferati ve
complex sclerosing lesion is suspected and e xcisional biopsy is lesions is diagnosed for the area of distor tion, and an adenosis
recommended. tumor with significant fibrosis is rep ted for the mass.
BI-RADS® category 4: suspicious abnor mality, biopsy should Complex sclerosing lesions can demonstrate f airly distinctive
be considered. mammographic, sonographic, and clinical findings. The mammo-
An oval mass with par tially obscured and indistinct mar gins is graphic findings for these lesions include disto tion with central 1- to
confi med on the spot compression views (Fig. 4.22G). Differential
2-mm locules of fat (i.e., no significant central density), long cu vi- neoplasia, ductal carcinoma in situ (usuall y low- or intermediate-
linear spicules, and better visualization in one of the two projections, grade), or tubular carcinoma is repor ted being associated with the
commonly the craniocaudal view. Round and punctate calcification lesion. For patients in whom a complex sclerosing lesion is in the
may be seen in as many as 30% to 40% of lesions. These lesions are differential, but the imaging and clinical findings are not diagnos
idiopathic and are not related to a prior biopsy or trauma. Unlike the tic, I do an imaging-guided biopsy; if a comple x sclerosing is
palpable findings one ould expect to find for a compara ly sized reported, I recommend excisional biopsy.
invasive ductal carcinoma, complex sclerosing lesions are usually not Alternatively, some recommend doing imaging-guided core
palpable. On ultrasound, normal tissue or a subtle area of distor tion biopsies on all of these lesions. If the lesion is a breast cancer , the
with some shadowing that is not necessarily confi med on the orthog- patient can then ha ve definit ve surgery. If a comple x sclerosing
onal image may be noted. lesion is diagnosed on the cores, some recommend e xcisional
For patients in whom, based on imaging and clinical findings, biopsy. Others have suggested that if the complex sclerosing lesion
suspect a complex sclerosing lesion, I recommend excision so that is not associated with ADH, the biopsy includes at least 12 speci-
the lesion can be evaluated in its entirety. In nearly 33% of patients mens, and the mammographic findings are reconciled with the his
with complex sclerosing lesions, atypical ductal hyperplasia, lobular tologic findings, no xcision is required.
I J
Figure 4.22. (Continued) Ultrasound image (H), radial projection of the mass in the upper outer quadrant of the left breast. Specimen radiograph (I), con-
fi ming excision of mass and adjacent area of distortion. Specimen radiograph (J), photographically coned to area of distortion.
PATIENT 23
Figure 4.23. Screening study, 77-year-old woman. Craniocaudal (A) and mediolateral (B)
oblique views.
larity is noted extending from the mass with calcifications t wards

Is this a normal study, or is additional evaluation
the nipple.
indicated? BI-RADS® category 0: need additional imaging evaluation.
A mass with associated calcifications is present medial y in the
right breast. Additionally, at least on the craniocaudal vie w, nodu-
C D
Figure 4.23. (Continued) Craniocaudal (C) and mediolateral oblique (D) spot compression magnification vi ws, right breast. When positioning for the addi-
tional views, the technologist notes nipple discharge.
patients initially diagnosed with a papilloma (with no atypia), 0% to

18% have been reported to have malignancy on excision.
you do next? In considering the literature on papillar y lesions, I think it is
important to reco gnize the relati vely low number of patients
A cluster of masses, one of which is associated with pleomorphic
described, the retrospective nature of some of the studies, and the
calcifications, is confi med on the spot compression magnifica
lack of adequate classification of lesions into central, usual y soli-
tion views obtained of the right breast. A biopsy is indicated. An
tary papillomas, and multiple peripheral papillomas. Additionally,
ultrasound is done to determine if the lesion can be identified fo
the follow-up on many of these patients is limited; 2 or 3 y ears of
imaging-guided biopsy. Because of the nipple discharge noted by
follow-up is probably insufficient to truly assess the biologic signif-
the technologist, additional histor y is obtained from the patient
icance of many of these lesions.
and, if indicated, physical examination and a ductogram are done.
Patients with centrall y occurring papillomas commonl y present
On questioning, the patient relates ha ving noticed her nipple
describing nipple discharge. The papillomas are often solitary, and on
dripping and dark bro wn spots on her bra and night clothes. On
excision, no significant proliferat ve changes are typically reported in
physical examination, nipple discharge is elicited easily from a sin-
the surrounding breast parenchyma. In contrast, multiple peripheral
gle duct opening. A ductogram (not sho wn) and ultrasound are
papillomas are usually detected mammographically as one or multi-
done for further evaluation.
ple masses that ma y have associated calcifications or as multipl
Multiple intraductal masses are imaged in the subareolar area in
clusters of pleomor phic calcifications. Associated proliferative
moderately dilated ducts. These are confi med on the ductogram (not
changes that include atypical ductal h yperplasia, lobular neoplasia,
shown). In addition, at least two solid masses, one of which has asso-
ductal carcinoma in situ (usuall y low-nuclear-grade), and invasive
ciated calcifications ( ig. 4.23I, thin ar row), are imaged at the
ductal carcinoma can be seen in nearly 50% of patients with multiple
2 o’clock position, 4 cm from the right nipple. Given the clinical and
peripheral papillomas. Also, following excisional biopsy of these
imaging findings, multiple papillomas and associated i vasive ductal
lesions, many patients present with recurrent lesions (new masses, or
carcinoma with ductal carcinoma in situ are the main considerations.
calcifications at the prior site). In the conte xt of multiple peripheral
papillomas, the term papillomatosis needs to be considered. This is a
be considered.
confusing term because some pathologists use it to describe multiple
An ultrasound-guided biopsy of the mass with associated calcifi
peripheral papillomas (i.e., lesions with a central fibr vascular core)
cations is done. An invasive ductal carcinoma with associated duc-
and others use it for intraductal hyperplasia. I think it is best to avoid
tal carcinoma in situ, high nuclear g rade with central necrosis, is
the term; however, when I am confronted with it, I specificaly ask the
reported on the core biopsy.
pathologist how he or she is using the term.
On the day of the lumpectomy, two wires are used to bracket the
As with so man y other situations in breast imaging, the clinical
intraductal lesions seen on ultrasound , close to the nipple and the
context is important in determining the appropriate management of
more peripheral cluster of masses.A 0.9-cm, grade III invasive duc-
patients with papillary lesions. The larger the lesion, the greater the
tal carcinoma with associated high-nuclear-grade ductal carcinoma
number of findings, and the older the patient, the more appropriat
with central necrosis is confi med in the lumpectom y specimen.
an excisional biopsy seems when a papilloma is diagnosed on core
A 0.9-cm, high-nuclear-grade ductal carcinoma in situ with apoc-
biopsy. It may be that patients with multiple peripheral papillomas
rine features is noted arising in an adjacent papilloma.Three excised
should be treated more aggressively and that excisional biopsy may
sentinel lymph nodes are normal [pT1b, pN0, pMX, Stage I].
be appropriate in this patient population follo wing an imaging-
The management of patients diagnosed with papillomas on core
guided biopsy. In this context, it is also impor tant to recognize that
needle biopsy remains contro versial. Clearly, papillary lesions with
distinguishing benign papilloma from papillomas with atypia and
atypia on core biopsy require excisional biopsy. The controversy cen-
papillary carcinoma may be difficult for the pathologist given core
ters on the diagnosis of a benign papillar y lesion with no associated
samples. As with the distinction between normal breast ductules and
atypia on core biopsy . Many authors adv ocate that these can be
tubular carcinoma, it is the presence or absence of m yoepithelial
followed with no excision required, while others recommend excision
cells that distinguishes benign from malignant papillary lesions, and
of all papillary lesions regardless of associated atypia.Among patients
as much as 10% of a malignant papillar y lesion has m yoepithelial
who have papillomas with associated atypia on core biopsy , 31% to
cells present, introducing the possibility of sampling bias.
60% have been repor ted to ha ve malignancy on e xcision. Among
E F
G H
Figure 4.23. (Continued) Ultrasound images in the subareolar area (E–G) and at the 2 o’clock position, 4 cm from the right nipple (H). Ultrasound image
(I) demonstrating the round solid mass with associated spicular echoes consistent with the calcifications seen mamm graphically (thin arrow) and a second
adjacent, irregular solid mass (thick arrow) at the 2 o’clock position, 4 cm from the right nipple. Specimen radiograph (J) demonstrating multiple masses, one
of which has associated calcifications in the specimen.The preoperative wire localization is done using ultrasound guidance. Two wires are used to bracket the
location of the intraductal lesions (seen on ultrasound) and the more peripheral cluster of masses seen mammographically.
PATIENT 24
Figure 4.24. Diagnostic evaluation, 71-year-old woman called back for evaluation of calcifi
cations in the left breast detected on her screening study . Craniocaudal (A) and mediolateral
oblique (B) spot compression magnification vi ws.
What would you recommend? on the specimen; and lastly, the location of the e xcised lesion in the
specimen is mark ed for the patholo gist to assure that the e xcised
A cluster of pleomor phic calcifications with roun , punctate, and lesion is evaluated histologically.
amorphous forms is confi med on the magnification vi ws. No def- For this patient, atypical ductal hyperplasia (ADH) is reported
inite linear for ms are present, and there is no linear orientation. histologically on the excised tissue. No further intervention is rec-
Fibrocystic changes including h yperplasia, atypical ductal h yper- ommended; however, a mammogram of this breast in 6 months is
plasia, columnar alteration with prominent apical snouts and secre- requested, to estab lish a ne w baseline for this patient. Our
tions (CAPSS), and sclerosing adenosis, as w ell as fibroadenoma approach to patients diagnosed with a high-risk mark er lesion
papilloma, and ductal carcinoma in situ (usually low- or intermedi- (e.g., ADH, lobular carcinoma in situ, atypical lob ular hyperpla-
ate-nuclear-grade, with no central necrosis) are in the dif ferential sia, papilloma with atypia, multiple peripheral papillomas, com-
for this cluster of calcifications. A stereotactically guided needle plex sclerosing lesions, CAPSS with atypia, and mucocele-lik e
biopsy is recommended; however, the patient is short of breath and lesions) is to obtain a mammo gram following the e xcisional
unable to lie prone. Excisional biopsy is scheduled follo wing wire biopsy so as to document post biopsy changes as they peak during
localization of the cluster of calcifications the first 6 months foll wing the biopsy. After the first 6 months
The specimen radio graph is obtained for se veral reasons. postbiopsy changes stabilize or slowly resolve. By evaluating the
Confi mation that the localized lesion is e xcised is the primar y rea- patient 6 months following the surgery, it is unlikely that a spicu-
son, and although the specimen is a tw o-dimensional representation lated mass at the biopsy site represents interval development of an
of a three-dimensional str ucture, if the localized abnor mality is in invasive lesion. Most impor tant, we avoid finding oursel es with
close proximity to the mar gins, it is equall y important that this is a spiculated mass at the biopsy site (of a high-risk lesion) 2 years
communicated to the surgeon. In evaluating the specimen, you also or more after the surgery, and not knowing if this is postoperative
want to make sure that the localization wire has been remo ved with change that is regressing or the development of a more significan
the specimen. Rarely, additional unsuspected lesions may be detected lesion.
C Figure 4.24. (Continued) Specimen radiography (C) obtained following wire

localization of the breast lesion.
PATIENT 25
B
Figure 4.25. Diagnostic evaluation, 61-year-old woman called back for e valuation of calcification
detected in the right breast on her screening mammo gram. Craniocaudal (A) and mediolateral oblique (B)
double spot compression magnification vi ws, right breast.
How would you define these findings? necrosis). The management of patients with this calcification type
particularly when diffusely involving the breast parenchyma bilat-
An area of amorphous calcifications is demonstrated on the magni erally, can be a challenge. In w omen with focal findings, pa ticu-
fication views. Differential considerations include fibro ystic larly if the calcifications represent a change compared with prio
changes, hyperplasia, atypical ductal h yperplasia, sclerosing studies or they are in an unusual location (e.g., inner quadrants as
adenosis, columnar alteration with prominent apical snouts and opposed to the upper outer quadrant of the in volved breast), I rec-
secretions (CAPSS), fibroadenoma, papilloma, and ductal carci ommend a stereotactically guided biopsy. Patients with more dif-
noma in situ (usually low-nuclear-grade with no central necrosis). fuse and bilateral findings pose more of a management issue
be considered.
Following preoperative wire localizations, the specimen is Do you sample or not? If you sample, how do you
placed in a container that allo ws for compression of the specimen decide where? If you sample and the pathology is
with an alphanumeric grid. Although we apply compression on the benign, can you be sure it is representative of all the
specimen, we try to minimize the amount of compression because calcifications?
recent reports in the literature suggest that vigorous specimen com-
pression may result in “false positive” histologic interpretations of My approach to patients with bilateral, dif fusely scattered amor-
tumor extending to the margins. The specimen radiograph is done phous calcifications is annual foll w-up with magnification vi ws;
using magnification technique on a mamm graphic unit, or a dedi- I recommend biopsy when changes in the calcifications or the sur
cated specimen radio graphy unit. The use of an alphanumeric rounding tissue are perceived on follow-up studies.
enables us to place a pin through the center of the lesion, or four Sclerosing adenosis is a component of fibro ystic change most
pins can be used to delineate the mar gins of larger lesions for the commonly seen in the perimenopausal period. It is a lobulocentric
pathologist. This assures that the area of mammographic concern is lesion characterized by disordered proliferation of epithelial, myoep-
fully evaluated histologically. Extensive sclerosing adenosis with ithelial, and stromal elements. This process is characterized b y an
associated calcifications is repo ted histologically. increased number of acini that are compressed and obliterated by the
proliferating intralobular stroma predominantly in the center of lob-
ules. More cystically dilated acini are seen at the peripher y of the
Are the imaging and histologic findings congruent?
involved lobules. Sclerosing adenosis is also characterized by hyper-
What do you recommend for this patient? plasia of the myoepithelial cells. It can occur as an isolated lesion or
as a component of complex sclerosing lesions, papillomas, fibroade
Yes, the imaging and histologic findings are con ruent. The excised
nomas (e.g., complex fibroadenomas), and i vasive or in situ cancers.
calcifications are identified as being associated with sclerosin
The imaging features of sclerosing adenosis are v ariable.
adenosis, and no atypia or other high-risk lesion (e.g., comple x
Sclerosing adenosis ma y present as a palpab le or screen-detected
sclerosing lesion or papilloma) is described by the pathologist. The
mass, the margins of which may range from w ell circumscribed to
patient is asked to return in 1 year.
indistinct to spiculated; it ma y also present as distor tion or focal
Calcifications with this appearance typicall y occur in w omen
parenchymal asymmetry, and associated calcifications m y be pres-
with dense glandular tissue and ma y demonstrate a focal but
ent. Alternatively, sclerosing adenosis may present with calcification
loosely clustered distribution, as in this patient, or the calcification
and no associated mass. One of three patterns may be seen relative to
may be diffusely scattered bilaterally. The differential to consider
calcifications developing in areas of sclerosing adenosis: a tight clus-
includes sclerosing adenosis, columnar alteration with prominent
ter of round and punctate, w ell-defined calcifications; loose y clus-
apical snouts and secretions (CAPSS), hyperplasia, atypical ductal
tered amorphous calcifications; or bilateral, di fusely distributed
hyperplasia, fibroadenoma, papilloma, and ductal carcinoma in sit
amorphous calcifications in the setting of dense glandular tissue
(commonly low- or intermediate-grade with no associated central
C Figure 4.25. (Continued ) Specimen radio graph (C), obtained to confi m

excision of the localized lesion and the wire.
PATIENT 26
A B
Figure 4.26. Screening study, 53-year-old woman. Right craniocaudal (A) and mediolateral oblique (B) views.
Postlumpectomy changes and sur gical clips are present in the

How would you describe these findings, and what
right breast at the lumpectom y site. Immediatel y following the
would you recommend next?
completion of the radiation therap y (Fig. 4.26D, E), there is
increased density at the lumpectom y site. The density pro gres-
A cluster of calcifications is detected medial y in the right breast.
sively resolves, and oil cyst formation is noted at the lumpectomy
Spot compression magnification vi ws are indicated for fur ther
bed. What do you think about the findings in the last set of fil
evaluation.
(Fig 4.26J, K)? How would you report this study, and what is your
recommendation?
The magnification vi ws (the mediolateral oblique projection is
At this time, there is an ir regular 2-cm mass with indistinct
not shown) confi m the presence of a cluster of pleomorphic calci-
margins, shadowing, and associated pleomorphic and linear cal-
fications in the right breast. Ductal carcinoma in situ (DCIS) is the
cifications, some of which demonstrate a linear orientation. The
main differential consideration for these calcifications, and there
constellation of f indings is consistent with recur rent disease.
fore a biopsy is indicated. Because of the density associated with
Ultrasound-guided biopsy is done and confi ms the presence of
the calcifications, i vasion may be present. DCIS is diagnosed fol-
invasive ductal carcinoma and associated high-nuclear-grade ductal
lowing core biopsies, and is confi med on the lumpectomy. In addi-
carcinoma in situ (DCIS) with central necrosis. In retrospect, a den-
tion to the lumpectomy, the patient is treated with radiation therapy
sity is seen de veloping at the lumpectom y bed on the last set of
to the right breast.
images (Fig. 4.26J, K), obtained 42 months follo wing completion including a change in the size of the breast, increased density of
of treatment. A simple mastectomy with axillary dissection is done. the parenchyma, prominence of the trabecular markings, and skin
A 3-cm in vasive ductal carcinoma with associated high-nuclear - thickening.
grade DCIS and lymphovascular space involvement is reported his- Reported recurrence rates range from 5% to 19% in the first 5 t
tologically. No metastatic disease is identified in t o excised sen- 12 years following lumpectomy with radiation therapy, and from 4%
tinel lymph nodes [pT2, pN0(sn) (i), pMX; Stage II]. to 14% following mastectomy. Risk factors linked to recurrence fol-
Local recurrence (i.e., ipsilateral breast tumor recurrence, IBTR) lowing lumpectomy with radiation therapy include young age at the
following breast-conserving therapy or mastectomy is defined a time of presentation, e xtensive intraductal component, multifocal
the development of cancer in remaining ipsilateral breast tissue or disease, lymphovascular space involvement, large tumor size, high
skin or on the ipsilateral chest w all or skin, respectively. Regional histologic grade, tumor necrosis, and positive margins at the time of
recurrence is defined as the d velopment of cancer in remaining the original resection. Most recur rences occur at or near the site of
ipsilateral axillary lymph nodes, supraclavicular, infraclavicular, or the original tumor within the first 5 ears following treatment.
internal mammary lymph nodes. Postlumpectomy changes are v ariable but may include areas of
Follow-up protocols for patients after lumpectomy and radiation increased density, distortion, and spiculation at the site of the
therapy are variable. Some facilities follow patients with a history lumpectomy, often associated with skin thick ening and distortion.
of conservatively treated breast cancer at 6-month inter vals for 3, These changes are usually most prominent within the first ear fol-
5, or 7 years, and the contralateral breast at yearly intervals. Other lowing the surgery and then stabilize or pro gressively resolve. In
facilities obtain annual mammograms bilaterally on these patients. some patients, oil c yst formation and the de velopment of dys-
We recommend annual diagnostic mammo graphy for these trophic calcifications m y be seen at the lumpectom y site as the
patients and obtain routine craniocaudal and mediolateral ob lique area of density and distor tion decreases. Some patients de velop
views bilaterally as well as a spot magnification tangential vi w of postoperative fluid collections; these m y also stabilize or progres-
the lumpectomy site for the first 7 ears following the sur gery, sively decrease in size, sometimes resolving completely without the
after which we return the patient to screening. The development of need for any intervention. Radiation therapy changes more com-
new pleomorphic calcifications, a mass, or increasing density an monly involve the entire breast and include increased density and
distortion at or close to the lumpectom y site are mammo graphic prominence of the trabecular markings as well as diffuse skin thick-
findings that may be associated with a recurrence. Less commonly, ening. Radiation therapy changes typically resolve within the first
recurrences may be characterized b y diffuse breast changes, years following completion of the therapy.
Figure 4.26. (Continued) Spot compression magnification craniocaudal vi w (C), right breast.
D E
Figure 4.26. (Continued) Right craniocaudal (D, F, H, J) and mediolateral oblique (E, G, I, K) views, at 6, 18, 30, and 42 months follo wing comple-
tion of the initial treatment. Linear metallic marker seen on some of the images is used to indicate the site of the lumpectomy scar.
F G
H I
Figure 4.26. (Continued) Right craniocaudal (D, F, H, J) and mediolateral oblique (E, G, I, K) views, at 6, 18, 30, and 42 months following completion
of the initial treatment. Linear metallic marker seen on some of the images is used to indicate the site of the lumpectomy scar.
J K
L M
Figure 4.26. (Continued) Right craniocaudal (L) and mediolateral oblique (M) views, 11 months following the films sh wn in (J) and (K).
Figure 4.26. The patient now describes a “lump” at the lumpectomy site. Spot compression magnification cran
iocaudal view (N), right breast.
O P
Figure 4.26. (Continued) The patient now describes a “lump” at the lumpectom y site. Spot compression magnification craniocaudal vi w (N), right
breast. Ultrasound images, transverse (TRV) (O) and longitudinal (LON) (P) projections of the mass in the right breast at the 1 o’clock position, 8 cm from
the nipple.
PATIENT 27
Figure 4.27. Diagnostic evaluation, 56-year-old patient presenting with a “lump” in the left
breast. Craniocaudal (A) and mediolateral oblique (B) views.
D E
Figure 4.27. (Continued) Exaggerated craniocaudal (C) spot compression view of palpable finding, left breast. Ultrasound images, radial (RAD) (D)
and antiradial (ARAD) (E) projections of palpable mass at the 2 o’clock position, posteriorly (Z3) in the left breast.
linear calcifications, the histol gic diagnosis can be predicted fairly

accurately. The clinical and imaging findings are consistent with
recommendation? poorly differentiated invasive ductal carcinoma with associated
ductal carcinoma in situ with central necrosis (probab ly high
On physical examination, a hard fi ed mass is palpated at the site of
nuclear grade). In patients with a high lik elihood of a malignancy,
concern to the patient. A solid, 2-cm mass with indistinct mar gins
the remainder of the breast and the ipsilateral axilla are scanned to
and spiculation, associated linear calcifications, and areas of shad
try and identify multifocal or centric disease and possibly abnormal
owing and enhancement is imaged cor responding to the palpab le
axillary lymph nodes.
finding. Given a round mass, with some enhancement and associated
F G
Figure 4.27. (Continued) Ultrasound images, radial (RAD) (F) and antiradial (ARAD) (G) projections, left axilla.
tomy with axillar y dissection follo wed by radiation therap y and

chemotherapy; or, being used with increasing frequenc y, neoadju-
recommendation?
vant therapy followed by either mastectom y or lumpectom y, an
axillary dissection, and radiation therapy for those patients having
A potentially abnormal lymph node is identified in the ipsilatera
a lumpectomy. If a mastectomy is done following neoadjuvant ther-
axilla. An adjacent nor mal-appearing lymph node is also noted.
apy, radiation therap y is not al ways recommended. Neoadjuv ant
Potentially abnormal lymph nodes are characterized b y absence or
therapy can decrease the size of, or eliminate, the tumor (i.e., down-
marked attenuation of the echogenic hilar region in conjunction with
stage the lesion), enabling some patients, who might not otherwise
thickening and bulging of the h ypoechoic cortex. In some patients,
be candidates for conser vative therapy, to under go lumpectomy.
potentially abnormal lymph nodes are nearly anechoic and no hyper-
This patient elects to undergo neoadjuvant therapy.
echoic hilar region is present. When a potentially abnormal lymph
After two courses of chemotherap y, the mass has decreased in
node is identifie , we recommend fine-needle aspiration o , depend-
size (Fig. 4.17H, I). In patients w ho undergo neoadjuvant therapy,
ing on the size and location of the yl mph node, a core biopsy (if it can
the initial findings m y resolve completely. Consequently, in
be done safely). In this patient, core biopsies are done on the mass in
patients who may elect to ha ve a lumpectom y after neoadjuv ant
the breast and of the potentiall y abnormal axillary lymph node. An
therapy, marking the location of the original lesion is impor tant so
invasive ductal carcinoma with associated ductal carcinoma in situ
that this area can be localized , excised, and evaluated for residual
and metastatic disease to the axillary lymph node are reported on the
disease. Given the significant response in this patient after t o
core biopsies. With the diagnosis of metastatic disease to an axillary
courses of chemotherapy, and with a planned lumpectom y if the
lymph node, the patient will under go a full axillar y dissection (i.e.,
tumor continues to respond, a “marking” clip is placed in the mass
sentinel lymph node biopsy is not indicated).
using ultrasound guidance (Fig. 4.27J).
Treatment options discussed with this patient include mastec-
tomy and axillar y dissection followed by chemotherapy; lumpec-
H I
Figure 4.27. (Continued) Ultrasound images, radial (RAD) (H) and antira-
dial (ARAD) (I) projections, of the mass at the 2 o’clock position, posteriorl y
J (Z3) in the left breast. Ultrasound image (J) documenting needle positioning in
the center of the mass prior to deployment of the clip.
K L
Figure 4.27. (Continued) Craniocaudal (K) and 90-degree lateral (L) views of the left breast, photographically coned, documenting clip location.
Clips to mark the location of a lesion are deployed at the time of of the biopsy and treatment choice is not al ways known), the clip
imaging-guided biopsies when a lesion (e.g. a cluster of calcifica can be deployed during the therapy in those patients in w hom the
tions or a small mass being biopsied with an 11G vacuum-assisted original lesion is responding and ma y resolve completely prior to
device), which may be malignant, might be removed in its entirety the surgery.
as a result of the biopsy. In these patients, if a malignancy is diag- Following completion of her neoadjuv ant therapy, the patient
nosed and the original lesion has been remo ved completely, the undergoes a lumpectomy and full axillar y dissection. A 2-cm area
clip deployed at the time of imaging-guided biopsy marks the site of fibrosis, consistent with tumor r gression, is described at the site
of the lesion. At the time of the lumpectom y, the clip is localized of the clip. No residual tumor is identified. No metastatic disease i
so that the tissue sur rounding the original lesion can be e valuated identified in 11 excised axillary lymph nodes. Several of the lymph
histologically for residual disease. Similarl y, if it is kno wn that a nodes demonstrate areas of fibrosis consistent with tumor r gres-
patient will undergo neoadjuvant therapy, and because the lesion sion [ypTX, ypN0, ypMX]. As in this patient, approximately 15%
may resolve as a result of the therapy, a clip can be deployed in the to 20% of patients w ho undergo neoadjuvant therapy demonstrate
lesion at the time of the biopsy . If the lesion responds to therap y, complete response with no residual tumor identified histol gically
the clip is localized preoperati vely in those patients under going at the time of their surgical procedure. Reportedly, the subgroup of
lumpectomy so that the tissue at the site of the treated lesion can be patients with a complete pathologic response has higher relapse-free
evaluated histologically for residual disease. Alternatively, as in survival and o verall survival rates compared with patients with
this patient (because histology is not always predictable at the time residual disease at the time.
M N
Figure 4.27. (Continued) Diagnostic evaluation, patient presents describing a “lump” at the lumpectomy site, 6 months following neoadjuvant therapy and,
more recently, lumpectomy and radiation therapy. Craniocaudal (M) and mediolateral oblique (N) views, left breast.
Figure 4.27. (Continued) Ultrasound image (P) of mass at the lumpec-

tomy site, 2 o’clock position, left breast.
What is your diagnosis and recommendation?
On physical examination, a hard mass is palpated at the lumpectomy

site. On ultrasound, a well-circumscribed, complex cystic mass with
posterior acoustic enhancement is imaged corresponding to the pal-
pable finding. During the real-time po tion of the study, some of the
O spicular echoes and hyperechoic bands in the mass shift in position
and appear to be “floating” in the mass, respect vely. This is a post-
Figure 4.27. (Continued) Spot compression (O) view of palpable finding operative fluid collection requiring no inte vention unless a super-
imposed infection is suspected or it is causing significant discom
fort. A high recur rence rate is associated with aspiration. It is
critical, however, to reassure the patient that this is not a recur rence
How would you describe the findings, and what is your and that fluid collections are common foll wing lumpectomy. We
main consideration at this point? can expect that this will decrease in size and stabilize or resolv e
completely with time. Postoperative fluid collections typical y have
The overall density of the breast is increased , which is consistent a complex cystic appearance on ultrasound. As in this patient, many
with radiation therapy effect. A round mass with partially well cir- can be characterized as predominantly cystic, with spicular echoes,
cumscribed and obscured margins is imaged at the lumpectomy site septations, and mural nodules, w hereas others ha ve small c ystic
and corresponds to the site of concern to the patient. Although this spaces in what otherwise appears to be a solid matrix.
could represent a recurrence, given a complete pathologic response
to neoadjuvant therapy and the shor t time inter val between her
lumpectomy and the de velopment of this mass, a postoperati ve
fluid collection is the primary consideration. An ultrasound is done
for further evaluation.
PATIENT 28
A
B
Figure 4.28. Diagnostic evaluation, 8-year-old girl with a mass in the left subareolar area. Ultrasound image (A) of left subareolar area. Ultrasound
image (B) of the right subareolar area for comparison.
cysts, and fibroadenomas. Malignant causes are rare but includ

What is the diagnosis and recommendation?
metastatic disease (rhabdomyosarcoma, neuroblastoma, lymphoma)
and secretory carcinoma (a primary breast malignancy characterized
On physical examination, the left breast is more prominent than the
by large amounts of intra- and extracellular secretion and neoplastic
right, and a readil y mobile mass is palpated in the left subareolar
cells with granular eosinophilic cytoplasm). Although initially called
area. On ultrasound, an irregular area of hypoechogenicity with indis-
juvenile carcinoma because it w as associated with childhood and
tinct margins is imaged in the left subareolar area.A smaller but sim-
adolescence, it can occur in patients of all ages. Care is required in
ilar-appearing area is imaged in the right subareolar area.This is con-
the management of these patients, because sur gical removal of a
sistent with premature, asymmetric breast bud de velopment (a very
developing breast bud results in significant defo mity or f ailure of
similar appearance is seen when an ultrasound study is done in men
normal breast development. Consequently, fine-needle aspiration i
with gynecomastia). No further intervention is warranted.
the procedure of choice if a neoplastic process is a serious consider-
Breast masses in children and adolescents are often benign and
ation in this patient population.
include inflammato y conditions, premature breast bud development,
PATIENT 29
A B

patient presenting with a painful “lump” in the right
breast. Craniocaudal (A) and mediolateral ob lique
(B) views, right breast, with a metallic BB at the site of
C concern to the patient. Spot tangential (C) view of the
palpable finding
How would you describe the findings, and what would Depending on history and clinical findings, an inflammat y process,
you recommend next? posttraumatic/postsurgical fluid collection, and a galactocele migh
also be in the differential. Malignant considerations include invasive
On the routine views, a mass with obscured margins is imaged corre- ductal carcinoma not otherwise specifie , medullary carcinoma, or
sponding to the palpab le finding. On the spot tangential vi w, the metastatic disease. Although they are less lik ely given the patient’s
margins of the mass are par tially well circumscribed, indistinct and age, mucinous and papillar y carcinomas are also in the dif ferential.
obscured. Differential considerations include c yst, fibroadenom Correlative physical examination and an ultrasound are indicated for
(complex fibroadenoma, tubular adenoma), p yllodes tumor, papil- further characterization.
loma, pseudoangiomatous stromal h yperplasia, and focal fibrosis
D E
Figure 4.29. (Continued) Ultrasound images, radial (RAD) (D) and antiradial (ARAD) (E) projections of palpable finding, right breast
What is the diagnosis, and what would you there is no residual abnor mality postaspiration. Also, in some
recommend? patients, the needle ma y need to be redirected (i.e., the tip of the
needle is against the cyst wall) during the aspiration, to be sure that
On physical examination, there is a hard tender mass palpated at the all the fluid is aspirated. At this point, if I am doing a pneumoc ys-
12 o’clock position, 2 cm from the right nipple. On ultrasound, this togram, I stabilize the needle and replace the fluid-filled syrin
is an anechoic mass with posterior acoustic enhancement consistent with one holding air (half of the volume of the aspirated fluid), an
with a c yst. There is some ir regularity of a por tion of the w all. I then inject the air into the c yst (Fig. 4.29H). The air is imaged as
Following discussion with the patient, an aspiration is under taken, an echogenic line (Fig. 4.29I, arrows).
primarily for symptomatic relief. A pneumocystogram is also In this patient, 4 mL of serous fluid is aspirated and no residua
planned for further evaluation. abnormality is seen follo wing the aspiration. F or the pneumocys-
After establishing an approach that allo ws me to adv ance the togram, half of the v olume of fluid aspirated is replaced with ai
needle parallel to the transducer, I clean the skin and use lidocaine (Fig. 4.29H, I) and spot compression magnification vi ws of the
to anesthetize the skin. Then, using ultrasound guidance, I inject aspirated cyst are obtained (Fig. 4.29J, K). Possible wall irregular-
lidocaine in the tissue leading up to, but taking care to not go into, ity and thickening or intracystic lesions can be further evaluated on
the lesion. I use ultrasound guidance for administering the anesthe- the pneumocystogram. In this patient, the wall of the cyst is smooth
sia and for doing the aspiration, even in patients in whom the mass and well defined. No intra ystic lesion or wall abnormality is iden-
is palpable. Commonly, the advancing needle displaces the mass, or tified. Annual screening mammography is recommended.
indents the wall, but does not penetrate into the mass (I think this BI-RADS® category 2: benign finding
explains many of the patients w ho present for evaluation of a pal- Following cyst aspiration, I routinely inject air into the cyst cav-
pable mass following attempted aspirations that yielded no flui ity. Some have suggested that air injection following aspiration can
and yet we find a yst corresponding to the palpab le finding). B reduce the incidence of c yst recurrence. The air does not hur t the
visualizing the trajectory of the advancing needle, I can gauge the patient, and if it is helpful in minimizing the lik elihood of a recur-
amount of compression I need to appl y to effectively immobilize rence, it can be beneficial. or patients for w hom I am concer ned
the mass and the amount of controlled pressure I need appl y with about the presence of a mural or intracystic abnormality, spot com-
the needle so that the cyst wall is punctured. With the needle in the pression magnification vi ws of the c yst are done follo wing the
cyst, I pull the stylet out of the 20G spinal needle, attach a 10-mL injection of air (i.e., a pneumoc ystogram), to fur ther evaluate the
syringe, and aspirate. I watch on real time as I aspirate, to be sure wall of the cyst.
F G
H I
Figure 4.29. (Continued) Ultrasound images of aspiration. Preaspiration image, documenting needle positioning in the c yst (F), postaspiration image
demonstrating no residual abnormality (G) surrounding the needle, and image obtained following the injection of air (H). Ultrasound image following air
injection (I). Air is seen as an echogenic line (arrows).
Figure 4.29. (Continued) Pneumocystogram films. Spot compression magnification v ws of air -

filled yst, craniocaudal (J) and mediolateral oblique (K) projections.
PATIENT 30
Figure 4.30. Diagnostic evaluation, 55-year-old patient called back for evaluation of a cluster of calci-
fications in the left breast detected on her screening mammogram. Double spot compression magnificatio
view (A), craniocaudal projection.
cells. If calcifications are rem ved in the cores, the diagnosis is

What is your working diagnosis, and what is your
established. Consequently, I evaluate patients having a tight cluster
recommendation? of this type of calcifications with ultrasound. Although in some of
these patients a mass is identified son graphically in association
The magnification vi ws confi m a cluster of calcifications wit
with the calcifications, the prima y reason for doing the ultrasound
linear forms having irregular margins, clefts, and demonstrating
is not to detect or fur ther characterize the calcifications, but rathe
linear orientation. The main consideration with calcifications h v-
to determine whether I can use ultrasound guidance for the biopsy.
ing these features is ductal carcinoma in situ with central necrosis,
My preference is to do ultrasound-guided core biopsies because
likely high nuclear grade. Biopsy is indicated.
patients are more comfor table in a supine position with no breast
As described pre viously (see discussion with F igs. 4.18 and
compression, and no radiation is needed. If I can see the calcifica
4.19), these types of calcifications are close y associated with the
tions with ultrasound, I can target them.
malignant cells. Targeting the calcifications ta gets the malignant
B C
Figure 4.30. (Continued) Ultrasound images (B, C) done in the upper outer quadrant of the left breast at the expected location of the calcifications
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What do you think? are done through this area, and core radio graphs are obtained. If
calcifications are confi med on the cores, nothing fur ther is done
Multiple spicular echoes (lar ge arrows, Fig. 4.30D, E) some with (remember that with this type of calcification, rem ving calcifica
associated shadowing (Fig. 4.30D, small arrows) are imaged at the tions targets the malignant cells directl y). If no calcifications ar
expected location of the calcifications seen mamm graphically in seen, additional cores are obtained.
the upper outer quadrant of the left breast. Three 14G core samples
E
Figure 4.30. (Continued) Ultrasound images (D, E) demonstrating echogenic foci (large arrows) in the
tissue consistent with the presence of calcifications. Shad wing (small ar rows) can be seen associated
with some of the echogenic foci.
F Figure 4.30. (Continued) Radiograph of three cores (F) obtained using

ultrasound guidance.
future, at this time that is not w hat I am trying to do. When I do a

What do you think? breast biopsy, I am trying to arrive at a correct diagnosis in the eas-
iest, least invasive, and most efficient way possible for my patient.
Calcifications are present in all of the cores. A high-nuclear-grade If the correct diagnosis can be established with a fine-needle aspi
ductal carcinoma in situ with central necrosis is diagnosed on the ration or one or tw o cores using a 14G needle, w hy do more? If
cores. there is no chance that I will remo ve a lesion in its entirety during
My approach to patient care is to do w hatever I need to do to the biopsy, why deploy a clip? Just because I can? I challenge y ou
arrive at the correct diagnosis as simply, easily, and efficient y as I to think methodically about what and how you do things to patients.
can. This is in the conte xt of complete, high-quality imaging Step back and ask yourself: What do I absolutely need to do to take
workups; I am not suggesting or adv ocating cutting cor ners or care of this patient optimally, and what is the easiest way to accom-
accepting suboptimal w ork—quite the opposite. Although I am plish the goal? Keep it simple!
sure that percutaneous treatment of small breast cancers is the
PATIENT 31
A B
Figure 4.31. Screening mammogram, 73-year-old woman. Craniocaudal (A) and mediolateral oblique (B) views, left breast, photographically coned to
an area of calcifications
the patient’s jacket, prior studies provide an explanation for the cal-
What do you think? Are magnification views indicated?
cifications. Vascular calcifications are also present
These are dense, coarse calcifications, most li ely dystrophic in eti-
ology. Magnification vi ws are not indicated. In looking through
C D
Figure 4.31. (Continued) Craniocaudal (C) and 90-degree lateral (D) views from a preoperative localization done for a mass in the left breast 4 years prior
to (A) and (B).
position when the needle is advanced in the breast. After you posi-
What approach was used for the localization, and what
tion the needle in the breast free-hand , craniocaudal (Fig. 4.31C)
are the limitations and possible complications inherent and 90-degree lateral (F ig. 4.31D) vie ws are obtained. In this
in this approach? What are the alternative options for patient the needle is through the lesion in both images (Fig. 4.31C,
preoperative wire localizations? D). However, this degree of accuracy is difficult to obtain and often
requires serial appro ximations. Depending on the relationship of
In this patient, the calcifications are dystrophic and localized to th the needle to the lesion on the initial images, free-hand adjustments
prior site. They require no further evaluation, intervention, or short- are made to the position of the needle.The images are repeated and,
interval follow-up. Annual screening mammo graphy is recom- based on the ne w position of the needle, additional adjustments
mended for the patient. may be indicated. This is done as many times as necessary to posi-
A free-hand anteroposterior , or frontal, approach w as used to tion the needle as close to the lesion as possib le (Fig. 4.31E–G).
localize the mass in the left breast. This is an acceptable method for Depending on the size of the breast, the size and location of the
preoperative localizations; ho wever, it is more of a challenge to lesion being localized, and the e xperience and persistence of the
localize lesions precisel y using this approach. Also, because the breast imager, having the needle consistentl y through or within
needle is advanced toward the chest wall, care should be exercised 5 mm of the lesion is hard to achie ve with this method. The issue
to minimize the possibility of a pneumothorax, par ticularly in thin then becomes what you are willing to accept as an adequate posi-
patients with small breasts. tion (distance) for the wire relative to the lesion: Is it acceptab le if
The main challenge in using this method is that it requires you to the wire is 1 cm or 1.5 cm from the lesion? Ideall y, you want the
establish the location of a lesion in the breast, based on images with wire to be within 5 mm of the lesion, and you do not want the wire
the breast compressed and pulled out a way from the body , and to be short of the lesion.
transpose this to a breast that is uncompressed and in its natural
A more accurate method in volves using breast compression needle. A repeat CC vie w is done to document final positioning
with an alphanumeric grid and an approach for needle placement Compression is released and the portion of the wire external to the
that is parallel to the chest w all. This is a simple and safe breast is secured on the skin.
approach that enables precise localization of even the smallest of After the wire is deployed, we do not compress the breast in a per-
lesions. Because the needle is adv anced in the breast parallel to pendicular direction to the wire because this can result in unwanted
the chest wall, the possibility of a pneumothorax is eliminated. changes in the position of the wire (e.g., the wire can be pulled out
The possible routes for needle entry using this approach include and end up short of the lesion, or the wire can be adv anced signifi
craniocaudal, caudocranial (i.e., from belo w), lateromedial, or cantly beyond the lesion). Because the wire is placed through the
mediolateral. The shortest distance from the skin to the lesion is needle, the position of the needle in the initial projection (Fig. 4.31J,
determined on craniocaudal and 90-de gree lateral vie ws (Fig. 90-degree mediolateral view in this example) describes the eventual
4.31H) of the breast, and this dictates the route tak en for needle position of the wire in this projection. There is no need, therefore, to
entry. The shortest distance to the lesion on the example provided repeat this projection (requiring you to compress the breast perpen-
is “s” cm using a mediolateral approach for the localization. A dicular to the wire) after the wire is deployed.
needle that is long enough to go 1 cm be yond the lesion is Lastly, preoperative wire localizations can be done using ultra-
selected (i.e., 1 cm “s” cm). sound guidance. My general r ule is that if I can see the lesion with
The breast is positioned for a 90-degree mediolateral view using ultrasound, I prefer to use ultrasound guidance for biopsies and pre-
the alphanumeric grid to compress the medial aspect of the breast operative wire localizations. In order to see the needle (and subse-
(Fig. 4.31I). The patient’s breast is k ept in compression after this quently the wire) in its entirety, I establish an approach that allows me
image is taken. The coordinates for the lesion are established on the to advance the needle in the breast parallel to the transducer . I use a
image (“B” and “3”) and using the collimator light (or laser light) a 25G, 1.5-in needle to inject lidocaine at the skin entr y site and in the
shadow of the lesion coordinates is cast on the breast. After anes- expected trajectory of the needle up to the lesion. I then adv ance the
thetizing the skin entry site with lidocaine, the needle is adv anced needle through the breast and into the lesion and verify that the needle
in the breast at the intersection point for the coordinates. If the is through the lesion longitudinally and in cross section (via orthogo-
patient has not moved from the time the initial image is done to the nal ultrasound images of the needle). Preferab ly with the tip of the
time you introduce the needle, and y ou selected a needle long needle 1 cm beyond the lesion, I deploy the wire, remove the needle,
enough to go beyond the lesion, you will have skewered the lesion. making sure that I do not inadvertently pull the wire out with the nee-
At this point, w e do another 90-de gree mediolateral vie w (Fig. dle, and obtain orthogonal ultrasound images of the wire (Fig. 4.31L).
4.31J) to document needle and, after deployment, wire positioning I measure the distance from the skin directl y down to the location of
in this projection and release compression. A craniocaudal vie w the lesion/wire for the surgeon and I place an “X” on the skin surface
using the spot compression paddle (Fig. 4.31J) is done next, and the directly over the lesion. A single mammographic image is obtained of
breast is kept in compression after this view is obtained. On the 90- the wire (Fig. 4.31M). The view used is selected so that compression
degree mediolateral view, the hub of the needle should be superim- of the breast occurs parallel (and not perpendicular) to the wire. After
posed on the lesion, and on the CC vie w, the needle should be the wire is deployed, we do not compress the breast per pendicular to
through or within 5 mm of the lesion and e xtend 1 cm beyond the the wire because this might result in changing the final wire position
lesion. If the needle is correctly positioned on the orthogonal views, ing (see F ig. 4.32). A radiograph or ultrasound of the specimen is
the wire is advanced through the needle and the needle is pulled out, always obtained following preoperative wire localizations to docu-
making sure that you do not inadvertently pull the wire out with the ment excision of the localized abnormality (Fig. 4.31N).
E F
Figure 4.31. (Continued ) Diagrams illustrating preoperati ve localiza-

tion using a free-hand anteroposterior approach for needle/wire placement.
With the breast uncompressed, the needle is advanced in the breast toward
the expected location of the lesion. Craniocaudal and 90-de gree lateral
(E) views are done to establish the relationship of the needle to the lesion.
Based on these initial images, the needle is repositioned and images are
repeated (F). Because the needle is still not in close proximity to the lesion
on orthogonal views, the needle is repositioned and another set of images
(G) is done. Depending on y our persistence, the needle ma y need to be
repositioned several times before it is close enough to the lesion to assure
adequate localization and e xcision. After the position of the needle is
deemed adequate, the wire is deployed. Depending on the size and location
of the lesion being localized, the size of the breast, and the experience of the
breast imager with this technique, accurate localizations using this
G approach may be more difficult
H I
J
Figure 4.31. (Continued ) Diagrams illustrating concepts of preoperati ve wire localization using breast compression with an
alphanumeric grid for a parallel-to-chest-wall approach. Ninety-degree and craniocaudal views of the breast (H) are reviewed, and the
distances from the various skin surfaces to the lesion are measured. The distance from the superior aspect of the breast to the lesion in
this example is “x” cm, the distance from the inferior aspect of the breast to the lesion in this example is “y” cm, the distance from the
lateral aspect of the breast in this example is “z” cm, and the distance from the medial aspect of the breast is “s” cm. The shortest dis-
tance from the skin to the lesion dictates the approach used for needle placement. In this e xample, the lesion is closest to th e medial
aspect of the breast, so a mediolateral approach is used. A needle long enough to go 1 cm be yond the lesion is selected. Using a com-
pression paddle that has a central fenestration surrounded by an alphanumeric grid, a 90-degree mediolateral view is done (I). The coor-
dinates for the center of this lesion are “B” and “3”. Using the collimator light, a shado w of these coordinates is cast on the patient’s
breast, lidocaine is used at the intersection point of these coordinates, and the needle is adv
anced in the breast. A second 90-degree medi-
olateral view is done (J). Because the wire is placed through the needle, this view describes the eventual trajectory and relationship of
the wire to the lesion in this plane. The hub of the needle (black square superimposed on the mass) is superimposed on the lesion. Next,
using the spot compression paddle, a craniocaudal view (J) is done to document the relationship of the needle to the lesion in the or thog-
onal projection. The breast is kept in compression in this projection until after the wire is deployed.
Figure 4.31. (Continued) The needle should be through or within 5 mm of the mass and 1 cm
beyond the lesion. If the tip of the needle is more than 1 cm beyond the lesion, the needle is pulled
out as much as needed for the tip to be 1 cm beyond the lesion. If the needle is associated with the
lesion on the orthogonal views (as in this example), the wire is deployed and another craniocaudal
view (K) is done to document final wire positioning. After the wire is deployed, the breast is not
compressed again in a projection that is per pendicular to the wire (the lateral projection in this
K example).
N M
Figure 4.31. Ultrasound image (L) obtained after the wire is deployed in a hypoechoic mass in the left breast. If the trajectory of the needle (and conse-
quently the wire) is parallel to the orientation of the transducer, the needle and wire can be seen in their entirety. In this patient, you can see the hook of the
wire and a portion of the reinforced wire segment in the mass. The distance from the skin to the mass is measured, and using an indelible marker, an “X” is
placed on the skin directly over the mass/wire as an additional guide for the surgeon. A mammographic image (M) obtained with compression applied par-
allel to the course of the wire is obtained to document the position of the wire in the lesion.A radiograph of the specimen (N) is obtained to verify excision
of the localized lesion and localization wire and to mark the location of the lesion for the patholo
gist. Alternatively, sonography of the specimen can be done
to document excision of the lesion and is indicated when the lesion is seen on ultrasound only (i.e., it is not seen mammographically).
485
PATIENT 32
A B
Figure 4.32. Preoperative wire localization, 47-year-old patient. Craniocaudal (A) and 90-degree lateral (B) views.
The problem with this wire localization is that the wires ended
How was this localization approached, and what do
up significant y beyond the lesions, as seen on the CC vie w. This
you think about the final position of the wires?
can occur if, after the wire is deplo yed, the breast is compressed
perpendicular to the direction in w hich the wire is deplo yed (Fig.
In this patient, two lesions in the right breast (a clip deplo yed after a
4.32C, D). In this patient the lateral vie w (Fig. 4.32B) was done
stereotactically guided biopsy is e vident in one of the lesions) are
after the wires w ere deployed, resulting in the inadv ertent reposi-
localized using a 90-degree lateromedial approach. The shortest dis-
tioning of the wires.
tance from the skin to the lesion being localized, as measured on cran-
An image is always done after the needle is placed in the breast
iocaudal (CC) and 90-degree lateral views, dictates the approach that
in the initial projection (see Fig. 4.31J). Because the wire is placed
is taken when the parallel-to-the-chest-w all approach using an
through this needle, the position of the needle describes the e ven-
alphanumeric grid is the method selected for preoperative wire local-
tual position of the wire in the initial projection. There is no need,
izations. In this patient, the lesions are closest to the lateral aspect of
therefore, to repeat this projection (requiring y ou to compress the
the breast on the CC view. Consequently, the needles/wires are placed
breast perpendicular to the wire) after the wire is deployed.
in the breast correctly using a 90-degree lateromedial approach.
CC
C D I. II. III.
Figure 4.32. Diagram illustrating the inadvertent repositioning of the wire that can result when breast compression is applied perpendicular to the direc-
tion of wire deployment (C). This can have an accordion effect so that the wire is advanced in, or pulled out, of the breast. After compression is released, and
the orthogonal view is obtained (D), the wire may have been advanced significant y beyond the lesion (I.), pulled out of the lesion (II.), or it may remain appro-
priately positioned (III.). While it is acceptable (though not desirable) to have the wire beyond the lesion, it is not accepta ble for the wire to be shor t of the
lesion (II.).
PATIENT 33
A B
Figure 4.33. Preoperative wire localization, 56-year-old patient. Ninety-degree lateral view (A) obtained after wire placement. Specimen radiograph (B).
we apply only a minimal amount of compression. The specimen

How was this localization done, and why were two
radiograph is done using magnification technique on a mammo
wires used? After reviewing the specimen radiograph, graphic unit, or a dedicated specimen radio graphy unit. The use of
what will you tell the surgeon? an alphanumeric grid enables us to place a pin through the center of
the lesion, or four pins can be used to delineate the margins of larger
This patient has pleomor phic calcifications in a s gmental distribu- lesions for the patholo gist. This assures that the area of mammo-
tion extending for approximately 6 to 7 cm in the upper outer (cran- graphic concern is fully evaluated histologically.
iocaudal view not shown) quadrant of the right breast. Two wires are The specimen radio graph is done to confi m that the localized
used for the localization to brack et the location of the calcification lesion is excised, assess gross margin involvement, document removal
for the surgeon. To excise a lesion completely, the use of two or more of the localization wire, potentiall y identify additional unsuspected
wires is recommended in some patients when the lesion spans several lesions, and mark the area of concern for the pathologist.
centimeters or when dealing with multifocal or multicentric disease. Because of the extent (6 to 7 cm) of the lesion in this patient, and
On the specimen radio graph, calcifications are noted xtending the difficulty in obtaining clear mar gins with an acceptable resulting
to the edges of the specimen. This is discussed directl y with the cosmetic effect, she went on to have a simple mastectomy. She also
surgeon at the time of the sur gery so that additional tissue can be had a sentinel l ymph node biopsy. Although sentinel l ymph node
obtained. Although the specimen is a tw o-dimensional representa- biopsies are not done routinely in patients diagnosed with ductal car-
tion of a three-dimensional str ucture, if the lesion of interest cinoma in situ (DCIS) on core biopsy, they are usually done in patients
approximates one of the margins, this is discussed with the surgeon. in whom an extensive area of DCIS is suspected based on the imaging
With the patient still in the operating room, additional tissue can be findings. In these patients, the lik elihood of microinvasive disease is
taken in an effort to minimize the likelihood that a second operative increased and, because of the extent of the disease, it is possib le that
procedure will be needed to obtain clear margins. not all of the tissue will be e valuated histologically. In this patient,
Following preoperative wire localizations, the specimen is placed high-nuclear-grade ductal carcinoma in situ with central necrosis is
in a container that allows for compression of the specimen with an diagnosed extensively involving the upper outer quadrant of the right
alphanumeric grid. However, based on recent reports in the literature breast. No invasion is identified in the tissue xamined. The excised
suggesting that vigorous specimen compression may result in “false sentinel lymph nodes are normal [Tis, pN0(sn) (i), pMX, Stage 0].
positive” histologic interpretations of tumor extending to the margins,
PATIENT 34
Figure 4.34. Diagnostic evaluation, 55-year-old patient being evaluated for a cluster of calcifications, posteromedial y in the
right breast. Craniocaudal (A) view, right breast. Craniocaudal (B) view, photographically coned to the cluster of calcifications
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Although no lucent-centered calcifications are identified in t A 90-degree mediolateral vie w using the spot compression
cluster, because of the close pro ximity to the skin, a skin location paddle with an alphanumeric g rid is obtained so that coordinates
for these calcifications is suspected. What can you do to prove that for the calcifications can be dete mined (Fig. 4.34C). The patient
these calcifications are on the skin and that biopsy is not needed? is maintained in compression until the coordinates for the calcifi
If these calcifications are in the skin, a tangential vi w of the skin con- cations are deter mined. A metallic BB is placed at C.5 and 2.5.
taining the calcifications should sh w that these are dermal. To obtain the Compression is released and a tangential view of the metallic BB
tangential view, a “skin localization” is done. Craniocaudal and ob lique is obtained. If the calcif ications are in the skin, the y will be
views are reviewed to establish the shortest distance from the skin to the imaged in tangent to the x-ray beam and in close association with
calcifications. In this patient, the calcifications are closest to the ski the metallic BB (Fig. 4.34D). If they are not on the skin, they will
on the medial aspect of the breast, so a 90-de gree mediolateral be imaged in the breast parench yma, not in tangent to the x-ra y
approach is taken. Normally, a regular, full compression paddle with beam and at a distance from the metallic BB . In this patient, the
an alphanumeric grid is used to compress the breast for localization. calcifications are der mal in location, and fur ther intervention or
However, having a spot compression paddle with an alphanumeric short-term follow-up is not indicated. Annual screening mam-
grid is helpful in reaching lesions in hard-to-access locations includ- mography is recommended.
ing the axillar y tail or an ywhere posteriorly in the breast. The spot BI-RADS® category 2: benign finding
compression paddle facilitates the inclusion of tissue that may other-
wise be difficult to include on an image with a full paddle
C D
Figure 4.34. (Continued). Image (C) of the right breast using a fenestrated, alphanumeric spot compression paddle to determine the coordinates for the
calcifications seen mammographically. Spot tangential (D) view of the metallic BB placed at the coordinates for the calcifications conf ming that these are
skin calcifications
■ BIBLIOGRAPHY Jacobs TW, Byrne C, Colditz G, et al. Radial scars in benign breast
biopsy specimens and the risk of breast cancer . N Engl J Med.
Agoff SN, Lawton TJ. Papillary lesions of the breast with and with- 1999;340:430–436.
out atypical ductal h yperplasia. Am J Clin Pathol. 2004;122: Jacobs TW, Chen YY, Guinee DG, et al. Fibroepithelial lesions with
440–443. cellular stroma on breast core needle biopsy . Am J Clin Pathol.
Asoglu O, Ugurlu MM, Blanchard K, et al. Risk f actor for recur- 2005;124:342–354.
rence and death after primar y surgical treatment of malignant Jacobs TW, Connolly JL, Schnitt SJ. Nonmalignant lesions in breast
phyllodes tumors. Ann Surg Oncol. 2004;11:1011–1017. core needle biopsies. Am J Surg Pathol. 2002;26:1095–1110.
Berg WA. Image-guided breast biopsy and management of high- Jacobs TW, Natasha P, George K, Schnitt SJ. Carcinomas in situ of
risk lesions. Radiol Clin N Am. 2004;42:935–946. the breast with indeter minate features: role of E-cadherin stain-
Berg WA, Mrose HE, Ioffe OB. Atypical lobular hyperplasia or lob- ing in categorization. Am J Surg Pathol. 2001;25:229–236.
ular carcinoma in situ at core-needle biopsy . Radiology. Kim JY, Han BK, Choe YH, Ko YH. Benign and malignant muco-
2001;218:503–509. cele-like tumors of the breast: mammo graphic and sonographic
Brenner RJ, Jackman RJ, Parker SH, et al. Percutaneous core nee- appearances. AJR Am J Roentgenol. 2005;185:1310–1316.
dle biopsy of radial scars of the breast: w hen is excision neces- Komenaka IK, El-Tmaer M, Pile-Spellman E, Hibschoosh H. Core
sary? AJR Am J Roentgenol. 2002;179:1179–1184. needle biopsy as a diagnotic tool to differentiate phyllodes tumor
Carder PJ, Garvican J, Haigh I, Liston JC. Needle core biopsy can from fibroadenoma. Arch Surg. 1003;138:987–990.
reliably distinguish betw een benign and malignant papillar y Liberman L. Clinical management issues in percutaneous core
lesions of the breast. Histopathology. 2004;46:320–327. breast biopsy. Radiol Clin North Am. 2000;38:791–807.
Carder PJ, Murphy CE, Liston JC. Sur gical excision is warranted Liberman L, Bracero N, Vuolo MA, et al. Percutaneous large-core
following a core biopsy diagnosis of mucocele-like lesion of the biopsy of papillary breast lesions. AJR Am J Roentgenol. 1999;
breast. Histopathology. 2004;45:148–154. 172:331–337.
Farshid G, Pieterse S, King JM, Robinson J. Mucocele-like lesions Liberman L, Sama M, Susnik B, et al. Lobular carcinoma in situ at
of the breast: a benign cause for indeter minate or suspicious percutaneous breast biopsy: surgical biopsy findings. AJR Am J
mammographic microcalcifications. Breast J. 2005;11(1):15–22. Roentgenol. 1999;173:291–299.
Fasih T, Jain M, Shrimankar J, et al. All radial scars/complex scle- Mercado CL, Hamele-Bena D, Oken SM, et al. Papillary lesions of
rosing lesions seen on breast screening mammograms should be the breast at percutaneous core-needle biopsy. Radiology. 2006;
excised. Eur J Surg Oncol. 2005;31:1125–1128. 238:801–808.
Foster MC, Helvie MA, Gre gory NE, et al. Lobular carcinoma in Page DL, Schuyler PA, Dupont WD, et al. Atypical lobular hyper-
situ or atypical lobular hyperplasia at core needle biopsy: is exci- plasia as a unilateral predictor of breast cancer risk: a retrospec-
sional biopsy necessary? Radiology. 2004;231:813–819. tive cohort study. Lancet. 2003;361:125–129.
Gill HK, Ioffe OB, Berg WA. When is a diagnosis of sclerosing Patterson JA, Scott M, Anderson N, Kirk SJ. Radial scar, complex
adenosis acceptable at core biopsy? Radiology. 2003;228:50–57. sclerosing lesion and risk of breast cancer . Analysis of 75 cases
Glazebrook K, Re ynolds C. Mucocele-lik e tumors of the breast: in Northern Ireland. Eur J Surg Oncol. 2004;30:1065–1068.
mammographic and sono graphic appearances. AJR Am J Ramsaroop R, Greenber g D, Tracey N, Benson-Cooper D .
Roentgenol. 2003;180:949–954. Mucocele-like lesions of the breast: an audit of 2 years at Breast
Greenstein-Orel S, Evers K, Yeh IT, et al. Radial scar with micro- Screen Auckland (New Zealand). Breast J. 2005;11(5):
calcifications: radiologic-pathologic correlation. Radiology. 321–325.
1992;183:479–482. Renshaw AA, Derhagopian RP, Tizol-Blanco DM, Gould EW .
Guerra-Wallace MM, Chistensen WN, White RL. A retrospective Papillomas and atypical papillomas in breast core needle biopsy
study of columnar alteration with prominent apical snouts and specimens. Am J Clin Pathol. 2004;122:217–221.
secretions and the association with cancer . Am J Surg. 2004; Rosai J. Borderline epithelial lesions of the breast. Am J Surg
188:395–398. Pathol. 1991;15:209–221.
Günhan-Bilgen I, Memis A, Üstün EE, et al. Sclerosing adenosis: Rosen EL, Bentley RC, Baker JA, et al. Image-guided core needle
mammographic and ultrasonographic findings with clinical an biopsy of papillar y lesions. AJR Am J Roentgenol. 2002;179:
histopathological correlation. Eur J Radiol. 2002;44:232–238. 1185–1192.
Hamele-Bena D, Cranor ML, Rosen PP. Mammary mucocele-like Rosen, PP. Rosen’s Breast Pathology. 2nd ed. Philadelphia:
lesions: benign and malignant. Am J Surg Pathol. 1996;20: Lippincott Williams & Wilkins; 2001.
1081–1085. Ung OA, Lee WB, Greenberg ML, Bilous M. Comple x sclerosing
Ivan D, Selinko V, Sabin AA, et al. Accuracy of core needle biopsy lesion: the lesion is complex, the management is straightforward.
diagnosis in assessing papillary breast lesions: histologic predic- ANZ J Surg. 2001;71:35–40.
tors of malignancy. Mod Pathol. 2004;17:165–171.
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Appendix: Breast Cancer TNM

Classification and Stage Grouping
■ PRIMARY TUMOR (same for clinical and pathologic pN0 No regional lymph node metastasis histologically;
classification) no additional examination for isolated tumor cells
(ITC)
TX primary tumor cannot be assessed pN0(i) No regional lymph node metastasis histologically,
T0 no evidence of primary tumor negative immunohistochemical (IHC) studies
Tis carcinoma in situ pN0(i) No regional lymph node metastasis histologically,
Tis(DCIS) ductal carcinoma in situ positive IHC, no IHC cluster 0.2 mm
Tis(LCIS) lobular carcinoma in situ pN0(mol) No regional lymph node metastasis histologically;
negative molecular findings (r verse transcriptase/
Tis(Paget) Paget disease of the nipple with no tumor
polymerase chain reaction, RT-PCR)
T1 tumor 2 cm or less in greatest dimension
pN0(mol) No regional lymph node metastasis histologically;
T1mic microinvasion 0.1 cm or less in greatest dimension positive molecular reaction (RT-PCR)
T1a tumor 0.1 cm but not 0.5 cm in greatest pN1 metastasis in 1 to 3 axillary lymph nodes and/or
dimension internal mammary lymph nodes with microscopic
T1b tumor 0.5 cm but not 1 cm in greatest disease detected by sentinel lymph node dissection
dimension but not clinically apparent (not detected by imaging
T1c tumor 1 cm but not 2 cm in greatest dimension studies or clinical examination)
T2 tumor 2 cm but not 5 cm in greatest dimension pN1mi micrometastasis (0.2 mm, none 2.0 mm)
T3 tumor 5 cm in greatest dimension pN1a metastasis in 1 to 3 axillary lymph nodes
T4 tumor of any size with direct extension to chest pN1b metastasis in internal mammary lymph nodes with
wall or skin microscopic disease detected by sentinel lymph
node but not clinically apparent (not detected by
T4a extension to chest wall but not including pectoral imaging studies or clinical examination)
muscle
pN1c metastasis in 1 to 3 axillary lymph nodes and in
T4b edema ( peau d’orange) or ulceration of the skin of internal mammary lymph nodes with microscopic
the breast, or satellite skin nodules confined to th disease detected by sentinel lymph node dissection
same breast but not clinically apparent (not detected by imaging
T4c both T4a and T4b studies or clinical examination). If associated with
T4d inflammato y carcinoma 3 positive axillary lymph nodes, the internal
mammary nodes are classified as pN3b
pN2 metastasis in 4 to 9 axillary lymph nodes, or in
clinically apparent internal mammary lymph nodes
■ REGIONAL LYMPH NODE (pathologic, pN) in the absence of axillary lymph node metastasis
pNX regional lymph nodes cannot be assessed pN2a metastasis in 4 to 9 axillary lymph nodes (at least
(previously removed or not excised) one tumor deposit 2.0 mm)
493
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494 Appendix: Breast Cancer TNM Classification and Stage Grouping
pN2b metastasis in clinically apparent (detected by imaging ■ DISTANT METASTASIS

studies, excluding lymphoscintigraphy or clinical
examination) internal mammary lymph nodes in MX distant metastasis cannot be assessed
the absence of axillary lymph node metastasis M0 no distant metastasis
pN3 metastasis in 10 or more axillary lymph nodes, or M1 distant metastasis
in infraclavicular lymph nodes, or in clinically
apparent ipsilateral internal mammary lymph nodes Stage 0 Tis N0 M0
in the presence of 1 or more positive axillary
Stage I T1 N0 M0
lymph node; or in 3 axillary lymph nodes with
clinically negative microscopic metastasis in inter- Stage IIA T0 N1 M0
nal mammary lymph nodes; or in ipsilateral supra-
T1 N1 M0
clavicular lymph nodes
T2 N0 M0
pN3a metastasis in 10 or more axillary lymph nodes (at
least one tumor deposit 2.0 mm), or metastasis to Stage IIB T2 N1 M0
the infraclavicular lymph nodes
T3 N0 M0
pN3b metastasis in clinically apparent ipsilateral mam-
mary lymph nodes in the presence of 1 or more Stage IIIA T0 N2 M0
positive axillary lymph nodes; or in 3 axillary T1 N2 M0
lymph nodes and in internal mammary lymph
T2 N2 M0
nodes with microscopic disease detected by sen-
tinel lymph node dissection but not clinically T3 N1 M0
apparent T3 N2 M0
pN3c metastasis in ipsilateral supraclavicular lymph
Stage IIIB T4 N0 M0
nodes
T4 N1 M0
(sn) sentinel lymph node T4 N2 M0

If surgery occurs after the patient has received neoadjuvant Stage IIIC Any T N3 M0
chemotherapy, hormonal therapy, immunotherapy, or radiation
therapy, the prefix “y” is used with the TNM classificatio Stage IV Any T Any N M0
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Patient List
■ CHAPTER 1: MY AUNT MINNIE PATIENT 37: Deodorant

PATIENT 38: Parasites, calcifie
PATIENT 1: Neurofibromatosi PATIENT 39: Pectoral lipoma
PATIENT 2: Seborrheic keratoses PATIENT 40: Keloids
PATIENT 3: Lymph nodes PATIENT 41: Shrapnel, bullet fragments
PATIENT 4: Fibroadenolipomas
PATIENT 5: Lipomas
PATIENT 6: Oil cysts ■ CHAPTER 2: SCREENING
PATIENT 7: Oil cysts
PATIENT 8: Oil cysts, reduction mammoplasty PATIENT 1: Technical issues, posterior nipple line
PATIENT 9: Fibroadenomas, popcorn calcification PATIENT 2: Normal variant, global parenchymal asymmetry
PATIENT 10: Fibroadenomas, popcorn calcification PATIENT 3: Normal mammogram, pseudolesion
PATIENT 11: Fibroadenomas, developing calcification PATIENT 4: Normal mammogram, pseudolesion
PATIENT 12: Fibroadenoma, coarse calcification PATIENT 5: Normal variant, focal parenchymal asymmetry
PATIENT 13: Vascular calcificatio PATIENT 6: Fat necrosis, postoperative distortion
PATIENT 14: Vascular calcificatio PATIENT 7: Invasive ductal carcinoma, not otherwise
PATIENT 15: Large rodlike calcification specifie
PATIENT 16 Milk of calcium PATIENT 8: Ductal carcinoma in situ
PATIENT 17: Dystrophic calcification PATIENT 9: Invasive ductal carcinoma with tubular features
PATIENT 18: Fibroadenoma, coarse, dystrophic calcification PATIENT 10: Effects of weight loss
PATIENT 19 Skin calcification PATIENT 11: Invasive ductal carcinoma not otherwise
PATIENT 20: Implant rupture specifie
PATIENT 21: Implant rupture PATIENT 12: Invasive ductal carcinoma not otherwise
PATIENT 22: Collapsed saline implant specifie
PATIENT 23: Implant rupture PATIENT 13: Arterial and large rodlike calcification
PATIENT 24: Hair PATIENT 14: Invasive mammary carcinoma, apocrine type
PATIENT 25: Artifact, Desitin PATIENT 15: Normal mammogram, pseudolesion
PATIENT 26: Hickman catheter cuff PATIENT 16: Ductal carcinoma in situ
PATIENT 27: Retained wire fragment PATIENT 17: Normal variant, focal parenchymal asymmetry
PATIENT 28: Retained needle tip PATIENT 18: Invasive lobular carcinoma
PATIENT 29: Skin folds craniocaudal views PATIENT 19: Invasive ductal carcinoma, not otherwise
PATIENT 30: Skin folds, mediolateral oblique views specifie
PATIENT 31: Sternalis muscle PATIENT 20: Invasive ductal carcinoma with apocrine
PATIENT 32: Nail crimp features
PATIENT 33: Finger prints PATIENT 21: Reduction mammoplasty
PATIENT 34: Poor film screen contac PATIENT 22: Edema, congestive heart failure
PATIENT 35: Nipple rings PATIENT 23: Arterial, large rodlike and dystrophic
PATIENT 36: Static calcification
495
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496 Patient List
PATIENT 24: Tubular carcinoma, lesion triangulation PATIENT 17: Mastitis

PATIENT 25: Global parenchymal asymmetry secondary to PATIENT 18: Cyst
surgery PATIENT 19: Fibromatosis (extraabdominal desmoid)
PATIENT 26: Invasive lobular carcinoma PATIENT 20: Ductal carcinoma in situ
PATIENT 27: Invasive ductal carcinoma, grade I with metas- PATIENT 21: Invasive ductal carcinoma, not otherwise speci-
tasis to axilla fie
PATIENT 28: Synchronous, bilateral breast cancers PATIENT 22: Gold in axillary lymph nodes
PATIENT 29: Changes following implant removal PATIENT 23: Gynecomastia
PATIENT 30: Normal variant, focal parenchymal asymmetry PATIENT 24: Complex sclerosing lesion
PATIENT 31: Invasive ductal carcinoma with prominent lobu- PATIENT 25: Fibrocystic complex with milk of calcium
lar features PATIENT 26: Invasive lobular carcinoma
PATIENT 32: Invasive ductal carcinoma, not otherwise speci- PATIENT 27: Changes related to a portable catheter (Port-A-
fied Cath)
PATIENT 33: Invasive lobular carcinoma PATIENT 28: Cat scratch disease
PATIENT 34: Normal mammogram, global parenchymal PATIENT 29: Diabetic fibrous mastopat y
asymmetry PATIENT 30: Invasive ductal carcinoma, not otherwise speci-
PATIENT 35: Invasive mammary carcinoma, micropapillary fied in male patien
type PATIENT 31: Trauma
PATIENT 36: Invasive ductal carcinoma with mucinous PATIENT 32: Invasive ductal carcinoma, not otherwise speci-
features fie , neoadjuvant therapy
PATIENT 37: Ductal carcinoma in situ PATIENT 33: Tubulolobular carcinoma
PATIENT 38: Normal mammogram, global parenchymal PATIENT 34: Ductal carcinoma in situ
asymmetry PATIENT 35: Galactocele
PATIENT 39: Invasive ductal carcinoma not otherwise PATIENT 36: Invasive ductal carcinoma, not otherwise speci-
specified; yst fie
PATIENT 40: Invasive ductal carcinoma, not otherwise PATIENT 37: Fibroadenoma
specifie PATIENT 38: Sclerosing adenosis
PATIENT 41: Synchronous bilateral breast cancers PATIENT 39: Lipoma and cyst
PATIENT 42: Poland’s syndrome PATIENT 40: Invasive ductal carcinoma, not otherwise speci-
PATIENT 43: Edema, congestive heart failure fie
PATIENT 44: Mondor’s disease, varix, healed PATIENT 41: Columnar alteration with prominent apical
PATIENT 45: Cysts snouts and secretions
PATIENT 42: Tubular adenoma
PATIENT 43: Metaplastic carcinoma
■ CHAPTER 3 DIAGNOSTIC BREAST IMAGING PATIENT 44: Multiple peripheral papillomas
PATIENT 45: Lymphoma, left axilla
PATIENT 1: Complex fibroadenoma; use of spot compres PATIENT 46: Metastatic lung carcinoma
sion and rolled views PATIENT 47: Fat necrosis
PATIENT 2: Invasive ductal carcinoma with tubular features, PATIENT 48: Sebaceous cyst, inflame
use of spot tangential view
PATIENT 3: Mucinous carcinoma, use of ultrasound
PATIENT 4: Ductal carcinoma in situ; use of double spot ■ CHAPTER 4: MANAGEMENT
compression magnification vi ws
PATIENT 5: Invasive mammary carcinoma with apocrine PATIENT 1: Fat necrosis, post surgical
differentiation, use of spot compression views PATIENT 2: Invasive ductal carcinoma, not otherwise speci-
PATIENT 6: Complex fibroadenoma and metaplastic carci fie
noma, lesion location and triangulation PATIENT 3: Multicentric disease: invasive ductal carcinoma,
PATIENT 7: Invasive ductal carcinoma, not otherwise speci- not otherwise specified and ductal carcinoma i
fie , use of spot tangential view situ
PATIENT 8: Invasive ductal carcinoma not otherwise speci- PATIENT 4: Invasive ductal carcinoma, not otherwise speci-
fie , axillary lymph node dissection and sentinel fie , correlation of mammographic and sono-
lymph node biopsy graphic finding
PATIENT 9: Hematoma, post-traumatic changes PATIENT 5: Abscess (subareolar)
PATIENT 10: Lactational adenoma PATIENT 6: Cyst
PATIENT 11: Granular cell tumor PATIENT 7: Cyst
PATIENT 12: Mucinous carcinoma PATIENT 8: Cyst, enlarging
PATIENT 13: Papillary carcinoma PATIENT 9: Fat necrosis
PATIENT 14: Abscess (peripheral) PATIENT 10: Intracystic papillary carcinoma
PATIENT 15: Synchronous bilateral invasive lobular PATIENT 11; Papillomas, nipple discharge
carcinomas PATIENT 12: Ductal carcinoma in situ, nipple discharge
PATIENT 16 Medullary carcinoma PATIENT 13: Multicentric disease, use of MRI
Patient List 497
PATIENT 14: Fibroadenoma, enlarging PATIENT 27: Invasive ductal carcinoma not otherwise speci-
PATIENT 15: Phyllodes tumor fie , metastasis to axilla, neoadjuvant therapy
PATIENT 16: Mucocele-like lesion and papilloma and postoperative seroma
PATIENT 17: Atypical ductal hyperplasia, ductal carcinoma PATIENT 28: Breast bud development
in situ apocrine type PATIENT 29: Cyst, pneumocystogram
PATIENT 18: Atypical ductal hyperplasia PATIENT 30: Ductal carcinoma in situ
PATIENT 19: Ductal carcinoma in situ PATIENT 31: Dystrophic calcifications; approaches to preop
PATIENT 20: Columnar alteration with prominent apical erative wire localizations
snouts and secretions and associated atypia and PATIENT 32: Preoperative wire localization, inadvertent repo-
atypical lobular hyperplasia sitioning of wires
PATIENT 21: Complex sclerosing lesion PATIENT 33: Preoperative wire localization: bracketing the
PATIENT 22: Complex sclerosing lesion and adenosis tumor lesion
PATIENT 23: Multiple peripheral papillomas and ductal carci- PATIENT 34: Skin calcifications, skin localizatio
noma in situ
PATIENT 24: Atypical ductal hyperplasia
PATIENT 25: Sclerosing adenosis
PATIENT 26: Ipsilateral breast tumor recurrence
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Index
Abnormalities Apocrine carcinomas, 122, 140, 142 mammography of, 431–433, 431f–432f,
of breast cancer, 88 mammography of, 119f–121f, 138f–139f 434–435, 434f, 441f–443f, 443, 452f, 453
in lymph nodes, 383, 466 MRI of, 140f–141f management of, 453
potential, 378 ultrasound of, 122f, 140f radiography of, 435f, 453, 453f
Abscess, 396 Appearance, patient care importance of, 230 ultrasound of, 433, 433f
around Dacron cuff, 48 Architectural distortion, 155 Atypical lobular hyperplasia (ALH)
mammography of, 395f differentials for, 94 biopsy of, 440
photograph of, 397f mammography of, 93f, 94, 95f LCIS v., 440
ultrasound of, 396f–397f Arterial calcifications, 240, 24 f–247f, 246, 324 mammography of, 182f, 184f–185f, 439f,
Adenoma, lactational mammography of, 21, 21f, 26f–27f, 28f–29f, 440
biopsy of, 267 47f, 96f, 97, 117f, 118, 148f, 150f–152f, ultrasound of, 186f
clinical presentation of, 268 205f–206f Audit. See Medical audit
histological features of, 268 with PXE, 26–27 Aunt Minnie, 1. See also Benign lesions
palpable mass as, 267 Artifacts Axillary lymph node dissection (ALND)
ultrasound of, 267, 267f, 268 in mammography, 47, 47f, 57, 57f for invasive breast cancer, 263
Adenoma, tubular negative-density, 56, 56f SLNB v., 263
biopsy of, 359 plus-density, 55, 55f, 389f, 390 Axillary nodal metastasis, 133, 163
imaging and histological features of, 359 Aspiration
mammography of, 357f–358f, 358–359 of ADH, 433 Bartonella henselae, cat scratch disease from,
palpable mass as, 358–359, 358f of bloody flui , 406, 406f–407f, 410–411 322
ultrasound of, 358–359, 358f of cysts, 398–399, 399f, 400, 474, 475f Batch interpretation, of screening mammo-
Adenosis fine-needle, 46 grams, 73
biopsy of, 349 for galactoceles, 342 BB. See Metallic BB
mammography of, 347f–348f, 348–349, for inflammato y lesion, 282 Benign epidermal tumors. See Seborrheic ker-
444f–446f, 446 of invasive carcinoma, 370 atoses, mammography of
radiography of, 446–447, 447f for invasive ductal carcinoma, 305 Benign lesions, 1–70
ADH. See Atypical ductal hyperplasia for lymph node, 466 amorphous calcifications as, 3 f–33f, 33–34,
Adiposis dolorosa, 64 of metaplastic carcinoma, 362 33f–34f
Air ultrasound-guided, 474, 475f artifacts as, 47, 47f, 57, 57f
injection of, 399, 474, 475f, 476f Assessment. See Breast Imaging and Reporting calcified parasites as, 6 f–62f, 62
in mammography, 3, 3f–4f, 51–52, 51f–52f, Data System cysts as, 14, 33–34, 33f–34f
65f, 66, 67f–68f Asymmetry, 192f–195f, 193, 211f dystrophic calcifications as, 19, 1 f, 22, 22f,
ALH. See Atypical lobular hyperplasia in breast size, 85f, 86 24, 24f–25f, 35f–37f, 36–37
ALND. See Axillary lymph node dissection mammography of, 182f, 183, 184f–185f, extracapsular implant rupture as, 39, 40f–41f,
Amorphous calcifications, 349, 355, 433–435 209f, 210 43f–45f, 44
440, 453, 455 in tissue distribution, 85f, 86, 90f, 91 fibroadenolipoma as, f–9f, 9
mammography of, 31f–33f, 201f–203f ultrasound of, 186f gel bleed as, 39
ultrasound of, 33–34, 33f–34f, 204f Atherosclerosis, mammographic signs of, hair as, 46f, 47
Amperage, for mammography, 26–27 Hickman catheter as, 48, 48f
110 Atypical ductal hyperplasia (ADH), 410, hyalinizing fibroadenomas as, 19, 1 f–25f,
Anesthesia, ultrasound-guided, 474 429–430, 436–437 21–22, 24, 36–37
Angle of obliquity, 78 aspiration of, 433 implants as source of, 39, 39f–45f, 42, 44
Antibiotics biopsy for, 434 intracapsular implant rupture as, 39
for cat scratch disease, 322 breast cancer and, 435 keloids as, 65f, 66, 67f–68f
for inflammato y lesion, 282 with CAPSS, 434–435 lipomas as, 10f, 11, 63–64f, 64
for mastitis, 396 DCIS v., 433, 435 lucent-centered calcifications as, 38, 3 f, 65f,
Antihistamines, 66 excisional biopsy for, 433–434, 443, 453 66, 67f–68f
499
500 Index
Benign lesions (continued) pregnancy and, 268 punctate, 244, 247f, 255, 285, 302, 311, 350,
lymph nodes as, 5–6, 5f–7f, 19, 23f–24f, 24, radiation therapy and lumpectomy for, 300f, 355, 433–435, 440, 444, 447, 453
52f, 60f, 63f 318f, 319 radiolucent mass with, 15f–18f, 18
milk of calcium as, 31f–34f, 33–34 statistics of, 72–73, 133 rim, 12f–14f, 14
negative-density artifact as, 56, 56f Breast cancer, male. See Male breast cancer rod-like, 28f–29f, 30, 117f, 118, 148f, 264f,
nipple rings as, 58, 58f Breast compression, with inflammato y carci- 265
oil cysts as, 11–12, 11f–13f, 12f–14f, 14, 18, noma, 291–292 round, 197f–198f, 199, 244, 255, 302, 311,
64 Breast hypoplasia, 217f, 218 313, 350, 417, 433–435, 440, 444, 447,
plus-density artifact as, 55, 55f Breast Imaging and Reporting Data System 453
radiolucent mass as, 10f–11f, 11–12, 14, (BI-RADS®) scattered, 222f–223f, 223
15f–18f, 18, 63f assessment categories of, 228–229, 378 skin, 38, 38f
rod-like calcifications as, 2 f–29f, 30 use of, 74, 155 spotted dystrophic, 264f, 265
seborrheic keratoses as, 2f–4f, 3, 5 Breast imaging consultations, 378 vascular, 219f–220f, 361
skin folds as, 26–27, 51–52, 51f–54f, 54, 60f Breast imaging, diagnostic, 227–375 Calcified parasites, mamm graphy of,
skin lesions as, 2f–4f, 3, 5 Breast lymphoma, 367 61f–62f, 62
sternalis muscle appearing as, 53f–54f, 54 biopsy of, 367 Calcium channel blockers, 66
vascular calcifications as, 26, 6 f mammography of, 366f, 367 Call-backs
wire fragments as, 49f, 50, 67f–68f palpable mass as, 367 patient management for, 74–76
Benign-type calcifications, 21, 240, 27 ultrasound of, 367, 367f rates of, 76
Bilateral diffuse changes. See Diffuse changes Breast self-examination (BSE), 72 CAPSS. See Columnar alteration with promi-
Biopsy. See also Excisional biopsy Breast size nent apical snouts and secretions
of adenosis, 349 asymmetries in, 85f, 86 Carcinoma. See Specific Carcinoma
for ADH, 434 decrease in, 108f–109f, 110, 155 Carcinoma, invasive. See Invasive carcinoma
of ALH, 440 Breast-within-a-breast. See Fibroadenolipoma Cat scratch disease, 322
breast cancer and, 228 BSE. See Breast self-examination histological features of, 322
of breast lymphoma, 367 Buck shot, mammography of, 69f, 70 imaging features of, 322
of calcifications, 355–356, 35 f, 437 Bullet fragments, mammography of, 69f, 70 mammography of, 321f, 322
for CAPSS, 440 ultrasound of, 321f, 322
of DCIS, 244, 249, 302, 332, 336, 339, 354, Calcification cluste , 348–349, 355, 385–388, Catheter, removal of, 319
418, 421, 456, 477 421, 437, 440, 456, 477, 489f CC view. See Craniocaudal view
of diabetic fibrous mastopat y, 325 mammography of, 100f–101f, 102, Change, fibro ystic, 418, 455
of ductal carcinoma in situ, 244, 249, 302, 126f–127f, 128, 164f–165f, 197f–198f, Changes. See also Diffuse changes
332, 336, 339, 354, 418, 421, 456, 477 385f–387f asymmetrical, 85f, 86, 155
of fibroadenoma, 346, 42 MRI of, 166f bilateral, 193f–195f
of fibromatosis, 29 ultrasound of, 386f with reduction mammoplasty, 144
imaging-guided v. excisional, 312 Calcifications, 18, 22. See also Calcifie symmetrical, 108f–109f, 110
indications for, 5–6, 105, 128, 133, 137, 152, parasites, mammography of Chemotherapy
159, 162, 165, 180, 199, 208, 216, 225, amorphous, 31f–33f, 33–34, 33f–34f, for DCIS, 466, 468
387, 411 201f–204f, 349, 355, 433–435, 440, 453, for invasive ductal carcinoma, 466
of inflammato y carcinoma, 293 455 Chest CT scan, of lipoma, 64f
of invasive carcinoma, 370 arterial, 21, 21f, 26–27, 26f–27f, 28f–29f, 47f, CHF. See Congestive heart failure
of invasive ductal carcinoma, 249, 260, 263, 96f, 97, 117f, 118, 148f, 150f–152f, Chondroid hamartomas, 9
305, 327, 332, 344, 354 205f–206f, 240, 245f–247f, 246, 324 Cleavage, in mammography, 209f, 210
of invasive lobular carcinoma, 285, 317 benign-type, 21, 240, 273 Clinical manifestations, of granular cell tumor,
of invasive mammary carcinoma, 336, 344 biopsy of, 355–356, 356f, 437 270
of lactational adenoma, 267 CAPSS with, 356 Collapse, of implant, 42, 42f
for male breast cancer, 327 in cysts, 33–34 Columnar alteration with prominent apical
of medullary carcinoma, 290 of DCIS, 30 snouts and secretions (CAPSS), 356
of metaplastic carcinoma, 362 difference in appearance of, 313–314, ADH with, 434–435
of mucinous carcinoma, 241 313f–314f biopsy for, 440
of papillary carcinoma, 278 double spot compression magnification of with calcifications, 35
previous, 94, 174, 188, 380 242, 242f mammography of, 439f, 440
of sentinel lymph nodes, 181 dystrophic, 19, 19f, 22, 22f, 24, 24f–25f, Comedo mastitis, 30
taking of, 228 35f–37f, 36–37, 85f, 86, 93f, 94, 155, Communication, patient care importance of, 230
of tubular adenoma, 359 205f–206f, 219f–220f, 324, 436, 481 Comparison studies
of tubular carcinoma, 238 eggshell, 12f–14f, 14 of diffuse changes with CHF, 144f–146f,
ultrasound-guidance for, 260, 336, 339, 367, indeterminate, 242 145–146, 219f–220f
428, 456, 477 with invasive lesion, 317 for evaluating mass changes, 112
Biopsy changes linear, 126f–127f, 128, 138f–139f, 140, indications for, 130, 135, 171, 210, 224–225
distortion as, 174, 188 164f–165f, 165, 197f–198f, 199, 244, 302, of invasive ductal carcinoma, 150f–152f, 152
following excision, 155, 174, 188 456 of lesion, 177f–178f, 178
BI-RADS®. See Breast Imaging and Reporting lucent-centered, 38, 38f, 65f, 66, 67f–68f, 255, of reduction mammoplasty, 18
Data System 490 for scattered densities, 148f, 149
Bloody flui , from cyst aspiration, 406, in lymph nodes, 306, 306f of weight loss, 108f–109f, 110
406f–407f, 410–411 macrolobulated mass with, 21, 21f Complex ductal carcinoma in situ, 385–388
Breast bud, development of, 471 mammography of, 12f–19f, 14, 19, 19f, 21–22, mammography of, 385f–387f
Breast cancer. See also Invasive breast cancer; 21f–24f, 23f–24f, 237, 245f–247f, 355–356, ultrasound of, 386f
Male breast cancer 355f–356f Complex fibroadenoma, 23
abnormalities of, 88 mixed-density mass with, 18 mammography of, 231f, 234f, 235, 250f, 252
ADH and, 435 oil cysts with, 12f–14f, 14 palpable mass as, 250f–251f, 251–252
biopsy and, 228 oval, 440 ultrasound of, 235, 235f, 251f, 252
detection of, 72 pleomorphic, 257, 260, 302, 308, 338, 349, Complex sclerosing lesion (CSL), 94, 311–312,
from fibroadenolipoma, 418, 421, 433, 435, 437, 440, 450, 453, 312, 381, 443–444, 446–447
invasive lobular carcinoma as, 285 456–457, 488 excision biopsy for, 447
Index 501
mammography of, 309, 309f–311f, 311, goal and approach to, 228 mastectomy for, 421, 466
441f–446f, 443, 446–447 philosophical considerations for, 229–230 MRI of, 165, 166f, 332, 333f, 421, 423f
ultrasound of, 311–312, 312f, 444, 447, 447f of women over 30, 228 with mucocele-like lesions, 430
Compression, for mammography films, 83, 110 of women under 30, 228, 267 palpable mass as, 337f–338f, 338–339, 353f,
135, 148f, 149 Diagnostic patient population 354
Congestive heart failure (CHF), diffuse changes description of, 227 papillomas v., 418
with, 144f–146f, 145–146, 219f–220f women with implants in, 227 presentation of, 339
Consultations, for breast imaging, 378 Differentials radiation therapy for, 456–457, 466
Contrast, for mammography films, 83, 11 for architectural distortion, 94 radiography of, 450, 451f, 478–479, 479f
Cooper ligaments, disruption of, 122, 140, 152 for diffuse breast changes, 110, 147, 221 SLNB use in, 263, 302, 332, 339, 354, 457,
Correlation, 377–378 for focal parenchymal asymmetry, 92, 130, 488
between imaging and pathology findings, 171 in spontaneous nipple discharge, 418
391 in males, 327 ultrasound of, 196f, 248f, 249, 301f, 302, 332,
between mammographic and ultrasound find of mass with radiolucent center, 380 333f, 335f, 336, 338–339, 338f, 409f–411f,
ings, 393f, 394f for mixed-density mass, 405 421, 423f, 450, 451f, 463f, 466f–467f, 470f,
Craniocaudal (CC) view, 73–74, 73f, 75f, 94 for patient discussions, 1 477, 477f–478f
lateral tissue visualization in, 213 for round mass, 402, 409 Ductal carcinoma, invasive. See Invasive ductal
pectoral muscles in, 80 Diffuse changes carcinoma
positioning for, 80, 213 with CHF, 144f–146f, 145–146, 219f–220f Ductal carcinoma NOS, invasive. See Invasive
Cribriform ductal carcinoma in situ, 192f–196f, differentials for, 110, 147, 221 ductal carcinoma not otherwise specifie
435 mammography of, 73, 110, 144f–145f, Ductal extension, of palpable mass, 354, 354f
mammography of, 177f–179f 219f–220f Ductography, 413
ultrasound of, 180f ultrasound of, 146f, 147 findings of, 41
CSL. See Complex sclerosing lesion Distortion, 172–173. See also Architectural of papillomas, 450
Cyst. See also Oil cyst distortion papillomas v. DCIS, 418
aspiration of, 398–399, 399f, 400 mammography of, 172f–175f, 182f, 184f–185f, pitfalls of, 418
bloody fluid in, 406, 40 f–407f, 410–411 187f, 188, 201f–203f, 380f–381f procedure for, 413
calcifications in, 33–3 perception skills for, 174 of spontaneous nipple discharge, 412f, 413
mammography of, 201f–202f, 224f–225f, ultrasound of, 175f, 186f, 204f Dystrophic calcifications, 36–37, 155, 324, 436
293f–294f, 294–296, 350, 350f–351f, 352, Diuretics, 221 481
374f–375f, 398f, 399, 401f, 403f, 472f Documentation, patient care importance of, 230 hyalinizing fibroadenomas with, 19, 22, 24
multiple cutaneous, 14 Double spot compression magnificatio 36–37
palpable mass as, 375, 375f of adenosis, 348–349, 348f mammography of, 19f, 22f, 35f–37f, 85f, 86,
pneumocystography of, 474, 475f–476f of ADH, 434, 434f 93f, 94, 205f–206f, 219f–220f
sebaceous v. epidermal inclusion, 375 of ALH, 439f spotted, 264f, 265
ultrasound of, 33–34, 33f–34f, 294–295, 295f, calcification screening y, 242, 242f ultrasound of, 24, 24f–25f
375, 398f, 399, 399f–400f, 400, 402f, 473f, of CAPSS, 439f
474, 475f of CSL, 311f Early detection, 379
of cyst, 294 Ecchymosis
Dacron cuffs, mammography of, 48, 48f of ductal carcinoma in situ, 337f, 338, 422f, mammography of, 328f, 329–330
DCIS. See Ductal carcinoma in situ 438 ultrasound of, 329–330, 329f
Density of invasive ductal carcinoma, 255–256, 256f Echoes, on ultrasound, 399, 400, 409–411
of parenchymal pattern, 92 of mammography, 228 EIC. See Extensive intraductal component
scattered, 148f, 149 minimizing blur on, 243–244 Epidermal inclusion cyst, sebaceous cyst v., 375
Deodorant, mammography of, 60, 60f of sclerosing adenosis, 455f Erythema, 396, 397f
Dercum disease. See Adiposis dolorosa setup for, 243, 243f with inflammato y lesion, 282
Description, for patient discussions, 1 Dubin device, 142 with invasive carcinoma, 370
Desitin. See Zinc oxide ointment Duct ectasia, 30 Estrogen use, 110, 171
Detection Ductal carcinoma in situ (DCIS), 102, Evaluation, of mammography films, 73–74,
early, 379 436–437 75f, 94
for patient discussions, 1 ADH v., 433, 435 Ewing sarcoma, radiation therapy for, 300f
rates of, 379 biopsy of, 244, 249, 302, 332, 336, 339, 354, Exaggerated craniocaudal (XCCL) view,
Diabetes, mammographic signs of, 26–27 418, 421, 456, 477 73, 80
Diabetic fibrous mastopat y calcifications of, 3 Excision
biopsy of, 325 with central necrosis, 126f–127f, 128, biopsy changes with, 155, 174, 188
histological features of, 325 138f–141f, 140, 140f, 142, 165, 197f–198f, of lesions, 142
mammography of, 323f, 325 199, 385f–387f, 436–437, 436f, 450, Excisional biopsy, 377–378
patients of, 325 464f–465f, 465–466, 466f–470f, 468, 470, for ADH, 433–434, 443, 453
ultrasound of, 324f, 325 477–479, 477f–479f for CSL, 447
Diagnosis, for patient discussions, 1 chemotherapy for, 466, 468 for fibroadenoma, 425, 42
Diagnostic breast imaging, 227–375. See also ducts involved in, 418 imaging correlation with, 391
Specific Carcinomas low-nuclear grade v. high-nuclear grade, 437 imaging-guided biopsy v., 312, 447
additional mammographic views, 228 lumpectomy of, 244, 249, 302, 332, 336, 339, for nipple discharge, spontaneous, 413–414,
approach to patient in, 230 354, 456, 466 414f, 418
BI-RADS assessment categories for, lymphovascular space involvement in, 457 for papillomas, 450
228–229 mammography of, 100f–101f, 119f–121f, for phyllodes tumor, 428
communication and documentation in, 230 138f–139f, 164f–165f, 165, 192f–195f, 242f, for sclerosing lesion, 429
goal and approach to, 228 245f–247f, 249, 300f–301f, 301–302, Exposure
introduction to, 227–228 331f–332f, 332, 334–336, 334f–335f, 337f, making of, 57
patient examples of, 231–375 338–339, 353–354, 353f, 408f–409f, for mammography films, 83, 11
philosophical considerations for, 229–230 415f–417f, 418, 420f, 421, 422f, 436–437, technical factors of, 109t
Diagnostic evaluation 436f, 438f, 448f–449f, 450, 456–457, uneven, 148f, 149
BI-RADS assessment categories for, 456f–463f, 464f–465f, 465–466, 468, Extensive intraductal component (EIC), for
228–229 468f–470f, 470, 477, 477f invasive ductal carcinoma, 249
502 Index
Extracapsular extension, of carcinoma, 133 mammography of, 340f, 341 Hypertension, mammographic signs of, 26–27
Extracapsular implant rupture, 39, 40f–41f, palpable mass as, 340f–341f, 341 Hypoplasia, of ipsilateral breast, 217f, 218
43f–45f, 44 ultrasound of, 341–342, 341f
Extravasated silicone, 39, 44, 45f Gardner syndrome, 64 Imaging algorithms, for breast imaging, 228
GCDFP-15. See Gross cystic disease flui Imaging-guided biopsy
False negative (FN), 379 protein excisional biopsy v., 312, 447
False positive (FP), 379 Gel bleed, 39 metallic clip for, 425, 468
Far posteromedial lesions, 208 Glands, in tubular carcinoma, 238 for phyllodes tumor, 429
Fat necrosis, 380–381, 406 Global parenchymal asymmetry, 86, 155 of sclerosing lesion, 429
dystrophic calcifications with, 3 mammography of, 154f, 155, 187f, 188, 199f, Implant rupture
imaging of, 18 200 mammography of, 39, 39f–41f, 43f, 45f
mammography of, 371f, 372–373 palpable mass with, 200 MRI of, 39
palpable mass as, 372f–373f, 373 Gold treatment ultrasound of, 39, 44f–45f
after reduction mammoplasty, 18 deposition in lymph nodes, 306 Implants. See also Implant rupture
ultrasound of, 372f–373f, 373 of rheumatoid arthritis, 306 collapse of, 42, 42f
Fibroadenolipoma Granular cell tumor in diagnostic patient population, 227
breast cancer from, 9 clinical manifestations of, 270 removal of, 168f, 169
mammography of, 8f–9f, 9 histological features of, 270 saline, 42
as palpable mass, 8f–9f, 9 mammography of, 269–270, 269f silicone, 39, 44, 45f
ultrasound of, 9 ultrasound of, 269–270, 269f Incident cancer detection rate, 379
Fibroadenoma, 425. See also Complex fibroade Gross cystic disease fluid protein (GCDFP-15) Infection. See Mastitis
noma; Hyalinizing fibroadenom 122 Inflammato y carcinoma
biopsy of, 346, 425 Gurgling echoes, 400 biopsy of, 293
excisional biopsy for, 425, 428 on ultrasound, 399 breast compression with, 291–292
mammography of, 345f, 346, 424f, 425 Gynecomastia, 308 mammography of, 291, 291f
palpable mass as, 346 histological features of, 308 ultrasound of, 292, 292f
phyllodes tumor v., 425, 428–429 mammography of, 307f, 308 Inflammato y lesion
ultrasound of, 346, 346f management options of, 309 erythema with, 282
ultrasound-guided biopsy for, 428 pathophysiological causes of, 308 mammography of, 280f–281f
Fibrocystic change palpable mass as, 281f
as nipple discharge cause, 418 H & E staining. See Hematoxylin-eosin ultrasound of, 282, 282f
sclerosing adenosis of, 455 staining Inframammary fold, 80
Fibromatosis, 299 Hair, mammography of, 46f, 47 Instructions. See Patient instructions, for
biopsy of, 299 Halo sign, 295 mammography
mammography of, 297f–298f, 298–299 of cyst, 294f, 295 Interferon, 66
management of, 299 of tubular adenoma, 358 Internal mammary artery, 117f, 118, 148f
palpable mass as, 298, 298f Hamartoma. See Fibroadenolipoma Interpretation
ultrasound of, 298–299, 298f Hematoma, 406 of CC view, 73–74, 73f, 75f
Fibrosis, 130, 171 evolution of, 266 of MLO view, 73–74, 74f–75f
Films mammography of, 264f–265f, 265–266 Intracapsular implant rupture, 39
contrast of, 83, 110 ultrasound of, 265–266, 265f Intracystic carcinomas, 399
evaluation of, 73–74, 75f, 94 Hematoxylin-eosin (H & E) staining, Intracystic papillary carcinoma, 410–411
exposure of, 83, 109t, 110, 148f, 149 180–181 mammography of, 408f–409f
finge prints on, 56, 56f Hemorrhagic tissue, 407f ultrasound of, 409f–411f
fogging of, 59, 59f Hereditary multiple lipomatosis, 64 Intraductal carcinoma, invasive. See Invasive
labeling of, 84 Hickman catheter, mammography of, intraductal carcinoma
quantum mottle in, 84 48, 48f Intraductal hyperplasia, as papillomatosis, 450
screen contact with, 57, 57f Histological features Invasive breast cancer, ALND v. SLNB, 263
sharpness of, 83–84 of cat scratch disease, 322 Invasive carcinoma
technical adequacy of, 73–74, 78–84, 94, 135 of diabetic fibrous mastopat y, 325 biopsy of, 370
Film-screen contact, 57, 57f, 83 of granular cell tumor, 270 mammography of, 368f–369f, 369–370
Fingerprints, 389f, 390 of gynecomastia, 308 with mucocele-like lesions, 430
on mammography films, 56, 5 f of invasive lobular carcinoma, 286 palpable mass as, 370, 370f
Fistula, 396, 397f of lactational adenoma, 268 ultrasound of, 370, 370f
Fluid overload, mammography of, 219f–220f of male breast cancer, 327 Invasive ductal carcinoma, 116, 140, 142, 152,
5-Fluorouracil, 66 of medullary carcinoma, 290 163, 167, 256–257, 385–388
FN. See False negative of metaplastic carcinoma, 362 asymmetry with, 86
Focal parenchymal asymmetry, 91–93, 91f–92f, of mucinous carcinoma, 274 biopsy of, 249, 260, 263, 305, 327, 332, 344,
155 of papillomas, 365 354, 456
differentials for, 92, 130, 171 of sclerosing adenosis, 455 chemotherapy for, 466
mammography of, 91–93, 91f–92f, 129f, 130, of tubular adenoma, 359 EIC for, 249
170f, 171 History lumpectomy of, 249, 305, 332, 344, 354, 466
palpable mass with, 200 of nipple discharge, 413 lymphovascular space involvement in, 305, 344
Focal skin change, approach to patient of patient, 94, 130, 171 mammography of, 96–99, 96f, 98f–99f, 103f,
with, 236 Hormone replacement therapy (HRT), 104, 105f, 107f, 111f–113f, 115f–116f, 134f,
Fogging, of mammography films, 59, 5 f mammographic signs of, 26–27 136f, 138f–139f, 150f–152f, 160f–162f,
Foreign bodies, in mammography, 51 HRT. See Hormone replacement therapy, 177f–179f, 201f–203f, 205f–207f, 209f,
Formation, of keloids, 66 mammographic signs of 211f–215f, 245f–247f, 249, 255–256,
4 D’s, for patient discussions, 1 Hyalinizing fibroadenoma, 8 255f–256f, 258, 258f–260f, 260, 263,
FP. See False positive with dystrophic calcifications, 19, 22, 24 303f–304f, 304–305, 326f, 327, 331f–332f,
36–37 332, 343f–344f, 344, 353–354, 353f,
Galactoceles, 342 mammography of, 19, 19f–24f, 21–22 382f–383f, 385f–387f, 436–437, 436f, 438f,
aspiration of, 342 ultrasound of, 24, 24f–25f 448f–449f, 450, 464f–465f, 465–466, 468,
imaging findings of, 34 Hyperplasia, 436–437 468f–470f, 470
Index 503
medullary carcinoma as subtype of, LCIS. See Lobular carcinoma in situ LM view. See 90-Degree lateromedial view
257, 290 Leser-Trélat sign, 5 Lobular carcinoma in situ (LCIS), 440
MRI of, 140f–141f, 332, 333f Lesion. See also Breast cancer; Lesion manage- ALH v., 440
with mucinous features, 192f–196f ment; Mass; Specific Carcinoma Lobular carcinoma, invasive. See Invasive
palpable mass as, 255–256, 255f, 304–305, anatomic locations of, 252, 252f–254f, 261, lobular carcinoma
304f, 353f, 354 262f Lobular neoplasia, 440
presentation of, 155 comparison studies of, 177f–178f, 178 in tubular carcinoma, 238
radiography of, 450, 451f excision of, 142 Location, of lesion, 114, 152, 153f, 183f–184f,
SLNB for, 305, 332, 334, 344, 354 extracapsular extension of, 133 261, 262f, 393f, 394f
treatment of, 466 of invasive lobular carcinoma, 186 rolled spot compression view for determining,
ultrasound of, 99f, 106, 106f, 114, 114f, 140f, locating of, 114, 152, 153f, 183f–184f, 393f, 233
153f, 163f, 167f, 180f, 204f, 207f, 215f, 256, 394f Lucent-centered calcification, 25
256f, 260–261, 261f, 263, 304–305, 304f, metachronous, 216 mammography of, 38, 38f, 65f, 66, 67f–68f,
326f, 327, 332, 333f, 344, 344f, 384f, 386f, multicentric, 216 388f–389f
450, 451f, 466f–467f, 470f multifocal, 216 Lump. See Lesion; Mass
Invasive ductal carcinoma NOS. See Invasive obvious, 74 Lumpectomy
ductal carcinoma not otherwise specifie papillary, 180 for breast cancer, 300f, 318f, 319
Invasive ductal carcinoma not otherwise speci- presentation of, 91, 93 for DCIS, 244, 249, 302, 332, 336, 339, 354,
fied (NOS), 11 stability of, 74 418, 437, 456, 466
mammography of, 388f–389f, 394f synchronous, 216 fluid collections foll wing, 470
presentation of, 94 tools for evaluating, 241 follow-up protocols for, 457
ultrasound of, 390f, 394f Lesion, inflammato y for invasive ductal carcinoma, 249, 305, 332,
Invasive intraductal carcinoma mammography of, 280f–281f 344, 354, 466
mammography of, 177f–179f, 209f, 211f–215f ultrasound of, 282, 282f for invasive mammary carcinoma, 336, 344
ultrasound of, 180f, 215f Lesion management, 377–490 metallic clip for, 456, 458f–462f, 468
Invasive lobular carcinoma, 133, 137 for ADH, 410, 429–437, 431f–435f, for metaplastic carcinoma, 362
abnormalities of, 88 441f–443f, 443, 452f –453f, 453 for mucinous carcinoma, 241, 274
asymmetry with, 8, 155 for ALH, 182f, 184f–186f, 439f, 440 recurrence following, 457
biopsy of, 285, 317 cancer detection rates in, 379 touch imprints during, 249
as breast cancer, 285 for CAPSS, 434–435, 439f, 440 of tubular carcinoma, 238
extent of, 186 for cribriform ductal carcinoma in situ, Lymph nodes
histological features of, 286 177f–180f, 435 abnormal, 466
mammography of, 131f–132f, 156f–158f, for CSL, 381, 441f–447f, 443–444, biopsy of, 181
172f–175f, 182f, 184f–185f, 283f–284f, 446–447 calcification in, 306, 30 f
285–286, 316f, 317 for DCIS, 408f–411f, 415f–417f, 418, cat scratch disease in, 322
picture of, 318f 420f–423f, 421, 423f, 430, 433, 435–437, examination for abnormality of, 383
presentation of, 86, 88, 94, 136, 147, 155 436f, 438f, 448f–449f, 450–451, 451f, gold treatment deposition in, 306
tubulolobular carcinomas as variant of, 336 456–457, 456f–467f, 463f, 465–466, 468, imaging features of, 362
ultrasound of, 133f, 137f, 159f, 175f, 186f, 468f–470f, 470, 477–479, 477f–478f mammography of, 5–6, 5f, 19, 23f–24f, 24, 52f,
285, 285f, 317, 317f ductography for, 412f, 413–414, 418, 450 60f, 63f, 87f, 88, 89f, 148f, 150f–152f, 224f
Invasive mammary carcinoma, 116. See also for fibroadenoma, 42 f, 425, 428–429 metastatic disease in, 133, 163, 362, 466
Metaplastic carcinoma FN in, 379 MRI of, 5–6, 7f
biopsy of, 336, 344 FP in, 379 ultrasound of, 5f–7f, 6
with focal mucinous features, 192f–196f for intracystic carcinoma, 399 Lymphoma, 367
lumpectomy of, 336, 344 for LCIS, 440 asymmetry with, 86, 155
mammography of, 115f–116f, 201f–203f, for lobular neoplasia, 440 biopsy of, 367
334–336, 334f–335f, 343f–344f, 344, medical audit of, 378–379 mammography of, 366f, 367
436–437, 436f, 438f for micropapillary ductal carcinoma in situ, ultrasound of, 367, 367f
micropapillary type, 189f–191f 189f–191f Lymphovascular space involvement, 131f–133f,
SLNB for, 344 for mucocele-like lesion, 430 133, 344, 387
ultrasound of, 204f, 335f, 336, 344, 344f for multiple peripheral papillomas, 450 in DCIS, 457
Invasive mammary carcinoma, apocrine type, for papilloma, 418, 448f–449f, 450, 451f in invasive ductal carcinoma, 305, 344
122, 140, 142 for papillomatosis, 450
mammography of, 119f–121f, 138f–139f for Phyllodes tumor, 425, 426f–428f, Magnetic resonance imaging (MRI)
MRI of, 140f–141f 428–429 of apocrine carcinomas, 140f–141f
ultrasound of, 122f, 140f pneumocystogram in, 474, 475f–476f of calcification cluste , 166f
Invasive micropapillary carcinoma PPV in, 379 of DCIS, 165, 166f, 332, 333f, 421, 423f
mammography of, 189f–190f sclerosing adenosis, 440, 454f–455f, 455 of DCIS with central necrosis, 140f–141f
ultrasound of, 191f for secretory carcinoma, 471 of ductal carcinoma in situ, 165, 166f, 332,
Isolated tumor cells, 181 sensitivity of, 379 333f, 421, 423f
specificity of, 37 of gel bleed, 39
Juvenile carcinoma, 471 TN in, 379 of implant rupture, 39
TP in, 378 indications for, 130, 140, 165, 167, 171, 216,
Keloids, mammography of, 65f, 66, 67f–68f Lidocaine, 398 421
Linear calcifications, 12 f–127f, 128, 140, of invasive ductal carcinoma, 140f–141f, 332,
Labeling, of mammography films, 8 197f–198f, 199, 244, 302, 456 333f
Lactational adenoma mammography of, 138f–139f, 164f–165f, of lymph nodes, 5–6, 7f
biopsy of, 267 165 of mucinous carcinoma, 274, 275f
clinical presentation of, 268 Lipoma of papillary carcinoma, 278, 279f
histological features of, 268 chest CT scan of, 64f scanning protocols for, 421
palpable mass as, 267 mammography of, 10f, 63f, 350, 350f–351f, screening with, 72
ultrasound of, 267, 267f, 268 352 Magnificatio
Language, patient care importance of, 230 radiolucent mass v., 11 minimizing blur in, 243–244
Lateral tissue, on CC views, 213 ultrasound of, 10f, 11, 64, 352, 352f obtaining, 243
504 Index
Male breast cancer of DCIS, 100f–101f, 119f–121f, 138f–139f, of invasive mammary carcinoma, 115f–116f,
biopsy for, 327 164f–165f, 165, 192f–195f, 242f, 245f–247f, 156f–158f, 201f–203f, 334–336, 334f–335f,
histological features of, 327 249, 300f–301f, 301–302, 331f–332f, 332, 343f–344f, 344, 436–437, 436f, 438f
mammography of, 326f, 327 334–336, 334f–335f, 337f, 338–339, of invasive mammary carcinoma with focal
prostate cancer and, 327 353–354, 353f, 408f–409f, 415f–417f, 418, mucinous features, 192f–195f
risk factors for, 327 420f, 421, 422f, 436–437, 436f, 438f, of invasive micropapillary carcinoma,
ultrasound of, 326f, 327 448f–449f, 450, 456–457, 456f–463f, 189f–190f
Males, differentials in, 327 464f–465f, 465–466, 468, 468f–470f, 470, of irregular mass, 96f, 98–99, 98f–99f
Malignancy 477, 477f of keloids, 65f, 66, 67f–68f
evaluation of mass suspected of, 383 of DCIS with central necrosis, 126f–127f, 128, of linear calcifications, 13 f–139f, 164f–165f,
indications of, 5–6 138f–141f, 140, 142, 165, 197f–198f, 165
Malignant lesions, ultrasound features of, 354 385f–387f, 436–437, 436f, 438f, 450, of lipoma, 10f, 63f, 350, 350f–351f, 352
Mammary carcinoma 464f–465f, 465–466, 468, 468f–470f, 470, of lobulated mass, 67f–68f
biopsy of, 249 477–479, 477f–479f of lucent-centered calcifications, 38, 3 f, 65f,
lumpectomy of, 249 of deodorant, 60, 60f 66, 67f–68f, 388f–389f
mammography of, 245f–247f, 249, 250f, of diabetic fibrous mastopat y, 323f, 325 of lymph nodes, 5–6, 5f, 19, 23f–24f, 24, 52f,
252 different views of, 228 60f, 63f, 87f, 88, 89f, 148f, 150f–152f, 224f
ultrasound of, 248f, 249, 251f, 252 of diffuse changes, 73, 110, 144f–145f, of macrolobulated masses, 21, 21f
Mammary carcinoma, invasive. See Invasive 219f–220f of macrolobulated masses with calcification
mammary carcinoma; Invasive mammary of disappearing mass, 123f–125f, 126 21, 21f
carcinoma, apocrine type of distortion, 172f–175f, 182f, 184f–185f, of male breast cancer, 326f, 327
Mammography. See also Screening 187f, 188, 201f–203f, 380f–381f of mammary carcinoma, 245f–247f, 249, 250f,
mammography of dystrophic calcifications, 1 f, 22f, 35f–37f, 252
of abscess, 395f 85f, 86, 93f, 94, 205f–206f, 219f–220f of mass with radiolucent center, 380f–381f
of adenosis, 347f–348f, 348–349, 444f–446f, of ecchymosis, 328f, 329–330 of medullary carcinoma, 287f–288f, 289–290
446 evaluation of, 73–74, 75f, 94 with metallic BB, 236, 236f, 240, 240f, 250f,
of ADH, 431–433, 431f–432f, 434–435, 434f, exposure in, 83, 109t, 110, 148f, 149 255, 255f, 269, 269f, 277f, 280f, 283f–284f,
441f–443f, 443, 452f, 453 of fat necrosis, 371f, 372–373 291f, 294, 294f, 297f–298f, 303f, 323f, 331,
air in, 3, 3f–4f, 51–52, 51f–52f, 65f, 66, of fibroadenolipoma, f–9f, 9 331f, 334f–335f, 337f, 357f, 366f, 368f, 374f
67f–68f of fibroadenoma, 34 f, 346, 424f, 425 of metaplastic carcinoma, 360f–361f, 361–362
of ALH, 182f, 184f–185f, 439f, 440 of fibromatosis, 29 f–298f, 298–299 of micromark clip, 150f–152f
of amorphous calcifications, 3 f–33f, of fluid verload, 219f–220f of milk of calcium, 31f–33f, 313–314,
201f–203f of focal parenchymal asymmetry, 91–93, 313f–314f
amperage in, 110 91f–92f, 129f, 130, 170f, 171 of mixed-density mass, 5, 5f, 9, 9f, 17f, 18
of apocrine carcinomas, 119f–121f, with fogged film, 59, 5 f of Mondor disease, 222f–223f, 223
138f–139f foreign bodies in, 50 of mucinous carcinoma, 239f–240f, 240, 271,
of architectural distortion, 93f, 94, 95f of galactoceles, 340f, 341 271f–272f, 273–274
of arterial calcifications, 21, 2 f, 26f–27f, of gel bleed, 39 of multiple masses, 224f–225f
28f–29f, 47f, 96f, 97, 117f, 118, 148f, of global parenchymal asymmetry, 154f, 155, of needle tip, 50f, 51
150f–152f, 205f–206f 187f, 188, 199f, 200 of negative-density artifact, 56, 56f
artifacts in, 47, 47f, 57, 57f of granular cell tumor, 269–270, 269f of nipple rings, 58, 58f
of asymmetry, 85f, 86, 182f, 183, 184f–185f, of gynecomastia, 307f, 308 of oil cysts, 11f–13f, 12
209f, 210 of hair, 46f, 47 of pacemaker, 219f–220f
of atypical lobular hyperplasia, 182f, of hematoma, 264f–265f, 265–266 of palpable mass, 6f, 8f–11f, 9, 12, 18,
184f–185f, 439f, 440 of Hickman catheter, 48, 48f 23f–24f, 43f, 45f, 382f–383f, 385f–386f,
after biopsy excision, 155 of hyalinizing fibroadenomas, 19, 1 f–24f, 395f, 404f–405f, 408f–409f
of breast lymphoma, 366f, 367 21–22 of papillary carcinoma, 276f–277f, 277
of buck shot, 69f, 70 of implant collapse, 42, 42f of papillomas, 363f–364f, 364–365,
of bullet fragments, 69f, 70 of implant removal, 168f, 169 448f–449f, 450
of calcification, 1 f–19f, 14, 18–19, 19, 19f, of implant rupture, 39, 39f–41f, 43f, 45f of parenchymal asymmetry, 192f–195f
21–22, 21f–24f, 23f–24f, 237, 245f–247f, of inflammato y carcinoma, 291, 291f patient instructions for, 60
355–356, 355f–356f of inflammato y lesion, 280f–281f pectoral muscles in, 1–52, 51f–52f, 54, 77f,
of calcification cluste , 100f–101f, 102, interpretation of, 73–74, 75f 78, 80, 135, 209f, 210, 217f, 218, 224, 224f
126f–127f, 128, 164f–165f, 197f–198f, of intracystic papillary carcinoma, of phyllodes tumor, 426f–427f, 428
385f–387f 408f–409f of plus-density artifact, 55, 55f
of calcified parasites, 6 f–62f, 62 of invasive carcinoma, 368f–369f, 369–370 of port-a-catheter, 318f, 319, 320f
of CAPSS, 439f, 440 of invasive ductal carcinoma, 96–99, 96f, positioning for, 77f, 78, 79f, 80–83, 81f–83f,
of cat scratch disease, 321f, 322 98f–99f, 103f, 104, 105f, 107f, 111f–113f, 87f, 88, 96f, 97, 135, 155, 197f, 198, 209f,
CHF findings on, 14 f–145f, 219f–220f 115f–116f, 134f, 136f, 138f–139f, 150f–152f, 210, 213
cleavage in, 209f, 210 160f–162f, 177f–179f, 201f–203f, 205f–207f, of preoperative wire localization, 485f–486f,
of complex ductal carcinoma in situ, 209f, 211f–215f, 245f–247f, 249, 255–256, 488f
385f–387f 255f–256f, 258, 258f–260f, 260, 263, radiolucency in, 3, 3f–4f, 5, 51–52, 51f–52f,
of complex fibroadenoma, 23 f, 234f, 235, 303f–304f, 304–305, 326f, 327, 331f–332f, 65f, 66, 67f–68f
250f, 252 332, 343f–344f, 344, 353–354, 353f, of radiolucent mass, 10f–11f, 11–12, 63f
compression in, 83, 110, 135, 148f, 149 382f–383f, 385f–387f, 436–437, 436f, 438f, of radiolucent mass with calcification
contrast in, 83, 110 448f–449f, 450, 464f–465f, 465–466, 468, 15f–18f, 18
of cribriform ductal carcinoma in situ, 468f–470f, 470 of reduction mammoplasty, 11f, 12, 15f, 18,
177f–179f of invasive ductal carcinoma NOS, 388f–389f, 143f–144f
of CSL, 309, 309f–311f, 311, 441f–446f, 394f of rod-like calcifications, 2 f–29f, 117f, 118,
443–444, 446–447 of invasive intraductal carcinoma, 177f–179f, 148f
of cysts, 201f–202f, 224f–225f, 293f–294f, 209f, 211f–215f of scattered calcifications, 22 f–223f
294–296, 350, 350f–351f, 352, 374f–375f, of invasive lobular carcinoma, 131f–132f, scheduling of, 60
398f, 399, 401f, 403f, 472f 156f–158f, 172f–175f, 182f, 184f–185f, of sclerosing adenosis, 454f–455f, 455
of Dacron cuffs, 48, 48f 283f–284f, 285–286, 316f, 317 of sclerosing lesion, 429–430, 429f–430f
Index 505
screening guidelines for, 72 mammography with, 236, 236f, 240, 240f, Neoadjuvant chemotherapy
screening views in, 73–74 250f, 255, 255f, 269, 269f, 277f, 280f, for inflammato y breast carcinoma, 332
of seborrheic keratoses, 2f–4f, 3, 5 283f–284f, 291f, 294, 294f, 297f–298f, 303f, for invasive ductal carcinoma, 332, 466,
sharpness in, 83–84 323f, 331, 331f, 334f–335f, 337f, 357f, 366f, 468
of skin calcifications, 38, 3 f, 63f, 65f, 66, 368f, 374f, 472f Neurofibromatosis,
67f–68f for skin lesion imaging, 3, 4f, 5, 490, 490f 90-Degree lateromedial (LM) view, 208
of skin folds, 51–52, 51f–54f, 54, 60f Metallic clip 90-Degree mediolateral (ML) view, 208
of skin lesion, 2f–4f, 3, 5, 100f, 205f for excised lesion, 434 Nipple, absence of, 217f, 218
of solid ductal carcinoma in situ, 177f–179f, for imaging-guided biopsy, 425, 468 Nipple discharge, spontaneous
201f–203f for lumpectomy, 456, 458f–462f, 468 causes of, 414
of spiculated mass, 105f, 156f–158f, with ultrasound guidance, 466 DCIS in, 418
160f–162f, 189f–190f, 205f–207f, 209f, Metaplastic carcinoma ductal carcinoma in situ as, 339
211f–215f biopsy of, 362 ductogram of, 412f, 413
of spontaneous nipple discharge, 412f, 413, clinical, imaging, and histological features of, evaluation of, 413
414f 362 excisional biopsy for, 413–414, 414f, 418
of sternalis muscle, 53f–54f, 54 lumpectomy of, 362 fibro ystic change as cause of, 418
of thrombosed vein, 222f–223f, 223 mammography of, 360f–361f, 361–362 mammography of, 412f, 413, 414f–417f,
of tubular adenoma, 357f–358f, 358–359 palpable mass as, 361–362 417–418, 419f
of tubular carcinoma, 236f–237f, 238 ultrasound of, 361–362, 362f papillomas as cause of, 418, 449f, 450
ultrasound correlation with, 393f–394f Metastatic disease. See also Micrometastatic Nipple ring, mammography of, 58, 58f
ultrasound progression from, 252, 252f–254f disease Node-positive patients, prognosis of, 133
of vascular calcifications, 6 f, 219f–220f in axillary lymph nodes, 133, 163 Noise, in mammography films, 8
of verrucous lesions, 5 of breast, 370, 471 Nonsteroidal, anti-inflammato y agents, 223
voltage in, 110 with extracapsular extension, 305
of weight loss changes, 108f–109f, 110 in lymph nodes, 133, 163, 362, 466 Oil cyst, 18, 155
of wire fragment, 49f, 50, 67f–68f in sentinel lymph node, 421 with calcification, 1 f–14f, 14
for women under 30, 267 Micromark clip, mammography of, 150f–152f development of, 266, 456
Mammography Quality Standards Act (MQSA), Micrometastatic disease, 180–181, 387 mammography of, 11f–13f, 12
assessment categories of, 228–229 Micropapillary carcinoma, invasive. See radiolucent mass as, 11, 14
Management. See Lesion management Invasive micropapillary carcinoma ultrasound of, 11–12, 11f, 64
Mass. See also Mixed-density mass; Palpable Micropapillary ductal carcinoma in situ, 435 Orthogonal images, for needle placement, 391,
mass; Radiolucent mass; Water-density Milk of calcium, 33–34, 399 392f
mass mammography of, 31f–33f, 313–314, Oval calcifications, 44
approach to patient with, 236 313f–314f
cluster of, 450 ultrasound of, 33f–34f, 314, 315f PABC. See Pregnancy-associated breast carci-
disappearing, 123f–125f, 126 Mixed-density mass, 155 noma
irregular, 96f, 98–99, 98f–99f, 383 calcification with, 1 Pacemaker, mammography of, 219f–220f
lobulated, 67f–68f differentials for, 405 Paget disease, ductal carcinoma in situ as,
macrolobulated, 21, 21f, 398f as fat necrosis, 372 339
mixed-density, 5, 5f, 9, 9f, 17f, 18, 155, 372, mammography of, 5, 5f, 9, 9f, 17f, 18 Palpable mass, 10f
405 ML view. See 90-Degree mediolateral view as breast lymphoma, 367
multiple, 224–225, 224f–225f MLO view. See Mediolateral oblique view with calcification cluste , 385–388
radiolucent, 10f–11f, 11–12, 14, 15f–18f, 18, Mondor’s disease, 222f–223f, 223 as complex fibroadenoma, 25 f–251f,
350, 351f, 352 mammography of, 222f–223f, 223 251–252
with radiolucent center, 380–381, 380f–381f ultrasound of, 223 as cyst, 375, 375f, 474
round, 138f–139f, 140, 401f–402f, 402, Mortality rates, of breast cancer, 72–73 as DCIS, 337f–338f, 338–339, 353f, 354
408f–409f, 409 Motion blur, 83, 110, 135 as ductal carcinoma in situ, 337f–338f,
spiculated, 105f, 115f–116f, 155, 156f–159f, MQSA. See Mammography Quality Standards 338–339, 353f, 354, 465
160f–162f, 168f, 169, 189f–191f, 205f–207f, Act ductal extension of, 354, 354f
209f, 211f–215f, 257, 260, 269–270, 269f, MRI. See Magnetic resonance imaging as fat necrosis, 372f–373f, 373
285, 308, 317, 336, 390, 390f Mucinous carcinoma, 257 as fibroadenolipoma, f–9f, 9
well-circumscribed, 402, 404f–406f, 405–406, histological features of, 274 as fibroadenoma, 34
408f–409f, 409–411 imaging features of, 274, 275f as fibromatosis, 298, 29 f
Mastectomy as invasive ductal carcinoma subtype, 257 following reduction mammoplasty, 18
for DCIS, 421, 466 invasive lesion as, 430 as galactoceles, 340f–341f, 341
for invasive ductal carcinoma, 466 lumpectomy of, 241, 274 with global parenchymal asymmetry, 200
Mastitis, 30, 94, 396 mammography of, 239f–240f, 240, 271, as inflammato y lesion, 281f
Mastitis obliterans, 30 271f–272f, 273–274 as invasive carcinoma, 370, 370f
Medical audit, 378–379 MRI of, 274, 275f as invasive ductal carcinoma, 255–256, 255f,
Mediolateral oblique (MLO) view, 73–74, palpable mass as, 240, 240f–241f 304–305, 304f, 353f, 354, 465
74f–75f, 94 ultrasound of, 241, 241f, 273f, 274 as lactational adenoma, 267
pectoral muscles in, 77f, 78 Mucocele-like lesions, 430 mammography of, 6f, 8f–11f, 9, 12, 18,
positioning for, 77f, 78, 79f Multicentricity, 216, 387 23f–24f, 43f, 45f, 382f–383f, 385f–386f,
Medullary carcinoma, 257 Multifocality, 216 395f, 404f–405f, 408f–409f
biopsy of, 290 Multiple cutaneous cysts, in steatocystoma mul- as medullary carcinoma, 289
histological features of, 290 tiplex, 14 as metaplastic carcinoma, 361–362
as invasive ductal carcinoma subtype, 257, Multiple peripheral papillomas, as papillomato- as mucinous carcinoma, 240, 240f–241f
290 sis, 450 with normal-appearing dense glandular tissue,
mammography of, 287f–288f, 289–290 Myxoid hamartomas, 9 382–384
palpable mass as, 289 as oil cyst, 11f, 12
ultrasound of, 289–290, 289f Needle, positioning of, 391, 392f, 400f as papillary carcinoma, 278
Metachronous, 216 Needle tip, mammography of, 50f, 51 as papillomas, 365, 365f
Metallic BB, 100f, 172f, 205f Negative-density artifact, in mammography, parenchymal asymmetry with, 200
for lump imaging, 11f 56, 56f as tubular adenoma, 358–359, 358f
506 Index
Palpable mass (continued) Plasma cell mastitis, 30 follow-up protocols for, 457
as tubular carcinoma, 237–238, 237f Pleomorphic calcification, 257, 260, 302, 308 for invasive ductal carcinoma, 466
ultrasound of, 6f, 10f, 11f, 24, 24f–25f, 338, 349, 418, 421, 433, 435, 437, 440, 450, recurrence following, 457
44f–45f, 405f–406f 453, 456–457, 488 Radiography
Papillary carcinoma, 257 Plus-density artifact, 389f, 390 of adenosis, 446–447, 447f
biopsy of, 278 mammography of, 55, 55f of ADH, 435f, 453, 453f
central v. peripheral, 278 pN1a, 133 of DCIS, 450, 451f, 478–479, 479f
imaging features of, 278 pN2a, 133 of excised lesion, 142f
as invasive ductal carcinoma subtype, 257 pN3a, 133 following wire localization, 50
mammography of, 276f–277f, 277 Pneumocystography, of cyst, 474, 475f–476f of invasive ductal carcinoma, 450, 451f
MRI of, 278, 279f Poland’s syndrome, 217f, 218 of papillomas, 450, 451f
palpable mass as, 278 Port-a-catheter of preoperative wire localization,
ultrasound of, 277–278, 278f mammography of, 318f, 319, 320f 485f, 488f
Papillomas ultrasound of, 319, 319f–320f of sclerosing adenosis, 455, 455f
DCIS v., 418 Positioning Radiolucency, in mammography, 3, 3f–4f, 5,
ductography of, 450 for CC view, 80, 213 51–52, 51f–52f, 65f, 66, 67f–68f
ducts involved with, 418 for mammography, 77f, 78, 79f, 80–83, Radiolucent mass, 10f, 11, 12
excisional biopsy for, 450 81f–83f, 87f, 88, 96f, 97, 135, 155, 197f, with calcification, 1 f–18f, 18
histological features of, 365 198, 209f, 210, 213 cluster of, 18f
mammography of, 363f–364f, 364–365, for MLO view, 77f, 78, 79f lipoma as, 350, 351f, 352
448f–449f, 450 of needle, 391, 392f, 400f lipoma v., 11
management of patients with, 450 for ultrasound, 237–238 mammography of, 10f–11f, 11–12, 63f
as nipple discharge cause, 418, 449f, 450 Positive prediction value (PPV), 379 oil cyst as, 11, 14
palpable mass as, 365, 365f Posterior acoustic enhancement, 405f–406f, 406, Reduction mammoplasty
radiography of, 450, 451f 409–411 changes with, 144
solitary v. peripheral, 365 on ultrasound, 398, 398f, 399–400, 399f comparison films of, 1
ultrasound of, 364–365, 365f, 450, 451f Posterior nipple line (PNL), 97, 135, 393f fat necrosis following, 18
Papillomatosis, 450 location of, 252, 253f–254f mammography of, 11f, 12, 15f, 18, 143f–144f
Parasites, calcifie , 61f–62f, 62 measurement of, 80, 80f, 82, 82f, 210 palpable mass following, 18
Parenchymal asymmetry. See also Focal Postoperative change, 380–381 Removal, of implant, 168f, 169
parenchymal asymmetry; Global parenchy- PPV. See Positive prediction value Retinoids, 66
mal asymmetry Predictors, of axillary lymph node metastasis, Rheumatoid arthritis, gold treatment of, 306
mammography of, 192f–195f 163 Rod-like calcifications, 30, 26 f, 265
ultrasound of, 196f Pregnancy, breast cancer and, 268 mammography of, 28f–29f, 117f, 118, 148f
PASH. See Pseudoangiomatous stromal hyper- Pregnancy-associated breast carcinoma (PABC), Rolled spot compression view
plasia 268 of arterial calcification, 24
Pathophysiological causes, of gynecomastia, Preoperative wire localization, 480–482, 481f, of mammography, 228
308 483f–485f, 486, 486f–487f when to use, 233, 233f
Patient care, 377 anteroposterior approach for, 482, 483f Round calcifications, 19 f–198f, 199, 244, 255,
approaches to, 230 concepts of, 484f–485f 302, 311, 313, 350, 417, 433–435, 440, 444,
communication and documentation for, 230 mammography of, 485f–486f, 488f 447, 453
for fibromatosis, 29 radiography of, 485f, 488f Rupture, of implants, 39, 39f–41f, 43f–45f
optimizing, 479 repositioning of, 486, 487f
philosophical considerations for, 229–230 ultrasound of, 485f Saline implants, 42
for sclerosing adenosis, 455 Presentation Satellite lesions, in tubular carcinoma, 238
Patient discussions, 1 of breast cancer, 88 Scanning protocols, for MRI, 421
Patient history, 94, 130, 171 of DCIS, 339 Scar markers, 155
Patient instructions, for mammography, 60 of invasive ductal carcinoma, 86, 155 Scars, hypertrophic, 66
Patient management, for additional evaluation, of invasive ductal carcinoma NOS, 94 Scattered calcifications, mamm graphy of,
74–76 of invasive lobular carcinoma, 86, 88, 94, 136, 222f–223f
Peau d’orange changes, 396 147, 155 Scattered densities, 148f, 149
Pectoral muscles of lactational adenoma, 268 Scattered dystrophic calcifications, 26 f, 265
in CC view, 80 of lesion, 91, 93 Scheduling, of mammography, 60
in mammography, 51–52, 51f–52f, 54, 77f, 78, of lymphoma, 86, 155 Sclerosed papillomas, dystrophic calcification
80, 135, 209f, 210, 217f, 218, 224, 224f of Mondor disease, 222f–223f, 223 with, 36
in MLO view, 77f, 78 Prevalent cancer detection rate, 379 Sclerosing adenosis, 349, 440
Perception, of distortion, 174 Prognostic factors, 133 imaging and histological features of, 455
Periareolar scar, 397f Prostate cancer, male breast cancer and, 327 mammography of, 454f–455f, 455
Periductal mastitis, 30 Pseudoangiomatous stromal hyperplasia radiography of, 455, 455f
Peripheral papillomas, solitary papillomas v., (PASH), 130, 171 Sclerosing lesion. See also Complex sclerosing
365 Pseudoxanthoma elasticum (PXE), 26–27 lesion
Peripheral vascular disease, mammographic Puerperal mastitis, 396 excisional biopsy for, 429
signs of, 26–27 Punctate calcifications, 244, 24 f, 255, 285, imaging-guided biopsy of, 429
Phyllodes tumor, 425, 428 302, 311, 350, 355, 433–435, 440, 444, mammography of, 429–430, 429f–430f
excisional biopsy for, 428 447, 453 Screening guidelines, for mammography, 72
fibroadenoma ., 425, 428–429 PXE. See Pseudoxanthoma elasticum Screening mammography, 72–225
imaging-guided biopsy for, 429 90-degree LM views for, 208
mammography of, 426f–427f, 428 Quantum mottle, 84 90-degree ML views for, 208
ultrasound of, 428, 428f amperage in, 110
Physical examination Radiation therapy of apocrine carcinomas, 119f–121f, 122, 122f,
indications for, 382, 396 for breast cancer, 300f, 318f, 319 138f–139f, 140, 140f–141f, 142
usefulness of, 381 breast density and, 470 axillary nodal metastasis in, 133, 163
Pinpoint tenderness, approach to patient with, for DCIS, 456–457, 466 batch interpretation of, 73
236 for Ewing sarcoma, 300f biopsy changes in, 155, 174, 188
Index 507
breast cancer statistics with, 72–73, 133 Skin folds Survival rates, of breast cancer, 133
call-back rates in, 76 mammography of, 51–52, 51f–54f, Synchronous, 216
CC views in, 73–74, 73f, 75f, 80, 94, 213 54, 60f
contrast in, 83, 110 with PXE, 26–27 T1 tumors, axillary lymph node metastasis with,
cysts in, 201f–202f, 224f–225f Skin lesion 163
DCIS in, 100f–101f, 102, 119f–121f, mammography of, 2f–4f, 3, 5, 100f, 205f Technical adequacy, of films, 73–74, 78–84, 94
126f–127f, 128, 138f–139f, 138f–141f, 140, metallic BB for imaging of, 3, 4f, 5 135
142, 164f–165f, 165, 166f, 192f–195f, 196f, Skin localization, 490 Thoracic artery, 117f, 118
197f–198f, 199 Skin retraction, 155 Thrombosed vein, mammography of, 222f–223f,
diffuse changes in, 73, 110, 144f–146f, Skin thickening, 155 223
145–147, 219f–220f, 221 SLNB. See Sentinel lymph node biopsy Tissue distribution, asymmetries in, 85f, 86, 90f,
distortion in, 172–174, 172f–175f, 182f, Solid ductal carcinoma in situ, 192f–196f, 91
184f–187f, 188, 201f–204f 435 TN. See True negative
exposure for, 83, 109t, 110, 148f, 149 mammography of, 177f–179f, 201f–203f Touch imprints, description of, 249
fibroadenoma in, 18 ultrasound of, 180f, 204f TP. See True positive
focal parenchymal asymmetry in, 91–93, Solitary papillomas, peripheral papillomas v., Triamcinolone, 66
91f–92f, 129f, 130, 155, 170f, 171 365 Triangulation, for locating lesions, 152, 153f
global parenchymal asymmetry in, 86, 154f, Specificit , 379 Trichinosis, calcifications with, 6
155, 187f, 188, 199f Spot compression paddle True negative (TN), 379
goal of, 72, 157 determining use of, 233 True positive (TP), 378
guidelines for easing imaging with, 241 Tubular adenoma
interpretation of, 73–74, 75f for mammography, 228, 232f, 247f biopsy of, 359
invasive ductal carcinoma NOS in, 94, 114 for skin localization, 490, 490f imaging and histological features of, 359
invasive lobular carcinoma in, 88, 94, Spot compression view mammography of, 357f–358f, 358–359
131f–132f, 133, 133f, 136, 137, 137f, 147, of ADH, 432, 432f, 452f palpable mass as, 358–359, 358f
155, 156f–158f, 172f–175f, 175f, 182f, of arterial calcification, 246, 24 f–247f ultrasound of, 358–359, 358f
184f–185f, 186, 186f of complex fibroadenoma, 250, 25 f Tubular carcinoma, 238, 257
isolated tumor cells in, 181 of CSL, 443, 443f glands in, 238
lymphovascular space involvement in, of cyst, 294, 350 as invasive ductal carcinoma subtype,
131f–133f, 133, 387 determining use of, 233 257
micrometastasis in, 180–181, 387 of fibroadenoma, 34 lobular neoplasia in, 238
MLO views for, 73–74, 74f–75f, 77f, 78, of galactoceles, 340f lumpectomy of, 238
79f, 94 of granular cell tumor, 269, 269f mammography of, 236f–237f, 238
of Mondor disease, 222f–223f, 223 indications for, 124, 127, 130, 171, 174, 178, palpable mass as, 237–238, 237f
PNL in, 80, 80f, 82, 82f, 97, 135, 210 225 presentation of, 94
of Poland syndrome, 217f, 218 of invasive ductal carcinoma, 255–256, 256f, satellite lesions in, 238
potential abnormalities in, 378 260, 260f, 332, 332f, 465 ultrasound of, 237–238, 237f
quantum mottle in, 84 of invasive lobular carcinoma, 284f Tubulolobular carcinoma, as variant of invasive
of reduction mammoplasty, 143f–144f, of lipoma, 350 lobular carcinomas, 336
144 of metaplastic carcinoma, 361, 361f Tumors, 72
sharpness in, 83–84 of milk of calcium, 313f–314f
of shrinking breast, 108f–109f, 110, 155 of mucinous carcinoma, 272f Ultrasound
triangulation in, 152, 153f of papillomas, 364 of abscess, 396f–397f
views for of tubular carcinoma, 236 of ADH, 433, 433f
voltage for, 110 Spot tangential view of ALH, 186f
XCCL views for, 73, 80 of cyst, 294, 375, 375f, 473 of amorphous calcifications, 33–34, 3 f–34f,
Screening views, 73–74 of diabetic fibrous mastopat y, 323f 204f
Screens, cleaning of, 57 of ductal carcinoma in situ, 334–335, 335f, of apocrine carcinomas, 122f, 140f
Sebaceous cyst, 375 353–354, 353f of asymmetry, 186f
calcifications with, 37 evaluating adequacy of, 240, 240f, of atypical lobular hyperplasia, 186f
epidermal inclusion cyst v., 375 256 of breast bud development, 471
Seborrheic keratoses, mammography of, 2f–4f, of fat necrosis, 372f of breast lymphoma, 367, 367f
3, 5 of fibromatosis, 29 f of calcification cluste , 386f
Secretory carcinoma, 471 of inflammato y lesion, 281f of cat scratch disease, 321f, 322
Secretory disease, 30 of invasive carcinoma, 369f CHF findings on, 147, 14 f
Sensitivity, 379 of invasive ductal carcinoma, 255, 255f–256f, of complex ductal carcinoma in situ, 386f
Sentinel lymph node biopsy (SLNB), 181 304f, 344, 344f, 353–354, 353f of complex fibroadenoma, 235, 23 f, 251f,
ALND v., 263 of invasive mammary carcinoma, 334–335, 252
for ductal carcinoma in situ, 263, 302, 332, 335f, 344, 344f of cribriform ductal carcinoma in situ,
339, 354, 457, 488 of mammography, 228 180f
for invasive breast cancer, 263 of medullary carcinoma, 288f of CSL, 311–312, 312f, 444, 447, 447f
for invasive ductal carcinoma, 305, 332, 334, of tubular adenoma, 358, 358f of cysts, 33–34, 33f–34f, 294–295, 295f, 375,
344, 354 of tubular carcinoma, 236, 237f 398f, 399, 399f–400f, 400, 402f, 473f, 474,
for invasive mammary carcinoma, 344 Squamous metaplasia, 396 475f
significance to results of, 26 Stability, of lesions, 74 of DCIS, 196f, 248f, 249, 301f, 302, 332, 333f,
touch imprints during, 249 Steatocystoma multiplex, 14 335f, 336, 338–339, 338f, 409f–411f, 421,
Sentinel lymph node, metastatic disease in, 421, Sternalis muscle, mammography of, 423f, 450, 451f, 463f, 466f–467f, 470f, 477,
436, 457 53f–54f, 54 477f–478f
Sharpness, in mammography films, 83–8 Steroid injections, 64, 66 of DCIS with central necrosis, 140f, 386f,
Shrinking breast, 108f–109f, 110, 155 Subareolar abscess formation, 396, 397f 466f–467f, 470f, 477, 477f–478f
Silicone gel, 66 Subareolar area of diabetic fibrous mastopat y, 324f, 325
Silicone implants, 39, 44, 45f invasive ductal carcinoma with, 257 of distortion, 175f, 186f, 204f
Skin calcifications, mamm graphy of, 38, 38f, spot compression view evaluation of, of dystrophic calcifications, 24, 2 f–25f
63f, 65f, 66, 67f–68f 233 of ecchymosis, 329–330, 329f
508 Index
Ultrasound (continued) of lactational adenoma, 267, 267f, 268 Ultrasound-guided aspiration, 474, 475f
echoes on, 398–399, 400 of lipoma, 10f, 11, 64, 352, 352f for cyst, 398, 475f
of fat necrosis, 372f–373f, 373 of lymph nodes, 5f–7f, 6 Ultrasound-guided biopsy, 260, 336, 339, 367,
features of malignant lesions, 354 of male breast cancer, 326f, 327 388–394, 428, 456, 477
of fibroadenolipoma, of mammary carcinoma, 248f, 249, 251f, 252 for fibroadenoma, 42
of fibroadenoma, 346, 34 f mammographic correlation with, 393f–394f Unilateral diffuse changes. See Diffuse changes
of fibromatosis, 298–299, 29 f mammography progression to, 252, 252f–254f
of galactoceles, 341–342, 341f of medullary carcinoma, 289–290, 289f Vascular calcification, 26, 361. See also Arterial
of gel bleed, 39 of metaplastic carcinoma, 361–362, 362f calcification
of granular cell tumor, 269–270, 269f of milk of calcium, 33f–34f, 314, 315f mammography of, 63f, 219f–220f
of hematoma, 265–266, 265f of Mondor disease, 223 Verrucous lesions, mammography of, 5
history obtained during, 229, 330, 342 of mucinous carcinoma, 241, 241f, 273f, 274 Voltage, for mammography, 110
of hyalinizing fibroadenomas, 24, 2 f–25f of multiple masses, 225
of implant rupture, 39, 44f–45f of needle positioning, 392f Water-density mass, 350, 351f, 352
indications for, 130, 171, 178, 185, 225, 256, of oil cysts, 11–12, 11f, 64 Weight loss, mammographic changes with,
382, 396, 409 of palpable mass, 6f, 10f, 11f, 24, 24f–25f, 108f–109f, 110
of inflammato y carcinoma, 292, 292f 44f–45f, 405f–406f Wire fragment, mammography of, 49f, 50,
of inflammato y lesion, 282, 282f of papillary carcinoma, 277–278, 278f 67f–68f
of intracystic papillary carcinoma, 409f–411f of papillomas, 364–365, 365f, 450, 451f Wire localization, 50, 394f
of invasive carcinoma, 370, 370f of parenchymal asymmetry, 196f for lesion excision, 142
of invasive ductal carcinoma, 99f, 106, 106f, of phyllodes tumor, 428, 428f preoperative, 480–482, 481f, 483f–485f
114, 114f, 140f, 153f, 163f, 167f, 180f, 204f, of port-a-catheter, 319, 319f–320f Women with implants, in diagnostic patient
207f, 215f, 248f, 249, 256, 256f, 260–261, positioning patients for, 237–238 population, 227. See also Implants; Young
261f, 263, 304–305, 304f, 332, 333f, 344, posterior acoustic enhancement on, 398–400, women
344f, 384f, 386f, 450, 451f, 466f–467f, 470f 398f–399f Wound healing, 66
of invasive ductal carcinoma NOS, 390f, 394f screening with, 72
of invasive intraductal carcinoma, 180f, 215f of solid ductal carcinoma in situ, 180f, 204f XCCL. See Exaggerated craniocaudal view
of invasive lobular carcinoma, 133f, 137f, of spiculated mass, 159f, 191f, 207f, 215f, 390f
159f, 175f, 186f, 285, 285f, 317, 317f transducer placement for, 114 Young women
of invasive mammary carcinoma, 159f, 204f, of tubular adenoma, 358–359, 358f invasive ductal carcinoma in, 134f, 136f
335f, 336, 344, 344f of tubular carcinoma, 237–238, 237f parenchymal pattern in, 92
of invasive mammary carcinoma with focal Ultrasound-guidance, for preoperative wire
mucinous features, 196f localization, 482, 485f Zinc oxide ointment (Desitin), 47
of invasive micropapillary carcinoma, 191f Ultrasound-guided anesthesia, 474 Zuska’s disease. See Subareolar abscess formation

Clinical Breast Imaging A Patient Focused Teaching File

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GRBQ187-2820G-FM[i-xiv].

qxd 10/07/2006 01:50 AM Page i Techbooks (PPG Quark)

A Patient Focused Teaching File

Gilda Cardeñosa, M.D

A Patient Focused Teaching File

Acquisitions Editor: Lisa McAllister

© 2007 by LIPPINCOTT WILLIAMS & WILKINS, a Wolters Kluwer business

Printed in the USA

Library of Congress Cataloging-in-Publication Data

To Mary Jones and Roxanne Aton

Last H1 Head vii

3 Diagnostic Breast Imaging 227

Appendix: Breast Cancer TNM Classification and Stage Grouping 493

Patient List 495

A Patient Focused Teaching File

■ INTRODUCTION ■ FOR PATIENT DISCUSSIONS

2 Chapter 1 • My Aunt Minnie

Clinical Breast Imaging: A Patient Focused Teaching File 3

do not let benign, obviously malignant, or clinical findings distrac

4 Chapter 1 • My Aunt Minnie

Clinical Breast Imaging: A Patient Focused Teaching File 5

technologist uses a BB , she indicates the reason on the w oman’s

Ultrasound is used adjuncti vely in patients in w hom a l ymph

6 Chapter 1 • My Aunt Minnie

Clinical Breast Imaging: A Patient Focused Teaching File 7

8 Chapter 1 • My Aunt Minnie

Clinical Breast Imaging: A Patient Focused Teaching File 9

and hyperechoic areas with disruption of normal tissue architecture.

10 Chapter 1 • My Aunt Minnie

Clinical Breast Imaging: A Patient Focused Teaching File 11

lipomas can be slightly hyperechoic and a small amount of poste-

Figure 1.6. Diagnostic study in a 60-year-old patient present-

12 Chapter 1 • My Aunt Minnie

BI-RADS® category 2: benign finding. ext screening mam-

Figure 1.7. Screening study, 49-year-old woman. Craniocaudal (A) view.

Clinical Breast Imaging: A Patient Focused Teaching File 13

Figure 1.7. (Continued) Mediolateral oblique view.

14 Chapter 1 • My Aunt Minnie

Steatocystoma multiplex is a rare, autosomal dominant condition

Clinical Breast Imaging: A Patient Focused Teaching File 15

Clinical Breast Imaging: A Patient Focused Teaching File 17

18 Chapter 1 • My Aunt Minnie

lishing a change in overall breast size following the surgery, as well

Clinical Breast Imaging: A Patient Focused Teaching File 19

decrease in size, an increase in density, and the development of dense,

20 Chapter 1 • My Aunt Minnie

Clinical Breast Imaging: A Patient Focused Teaching File 21

22 Chapter 1 • My Aunt Minnie

decreases slightly in size, becomes denser , and the calcification

Clinical Breast Imaging: A Patient Focused Teaching File 23

24 Chapter 1 • My Aunt Minnie

cally. The mammographic findings are diagnostic of a yalinizing

Clinical Breast Imaging: A Patient Focused Teaching File 25

26 Chapter 1 • My Aunt Minnie

patients (i.e., those on oral antihypertensives) compared to women

Clinical Breast Imaging: A Patient Focused Teaching File 27

patients (i.e., those on oral antihypertensives) compared to women

28 Chapter 1 • My Aunt Minnie

Clinical Breast Imaging: A Patient Focused Teaching File 29