Mammographic Appearance of Breast CancerBy:

Dr. Dorria SalemProfessor of Radiology

Cairo University-------------------------------------------------------------------------------------------------------

BI-RADSBreast Imaging Reporting And Data System

• Mammographic findings should be reported according to the Breast Imaging Reporting & Data system (BI-RADS), established by the American college of Radiology (ACR) :

-----------------------------------------------------------------------------------------------Benign Lesions1-Well defined

2-Regular outline

3- +/- Surrounding halo

4- +/- Macrocalcification----------------------------------------------------------------------------------------Commonest Benign Lesions

• Fibroadenoma• Cyst• Lipoma

-----------------------------------------------------------------------------------------------1)Fibroadenoma

• U/S: Ovoid= longer than deep.• Sharply defined margins.• Fairly uniform internal echoes.

-------------------------------------------------------------------------------------------------------2)CystMammogram:

• Rounded or ovoid, well defined.• Surrounding halo.• May show Egg shell calcification

Follow up : 1- disappear (resobed) 2-decrease in size. 3-increase in sizeU/S: rounded or oval sharply defined margins.

• No internal echoes.• Bright posterior acoustic enhancement

---------------------------------------------------------------------------------------------------- 1)Lipoma

• U/S: hypoechoic similar in echotexture to subcutaneous fat but distinguished from it by the capsule.

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ASure Signs of malignancy1-Mass: spiculated

2- Microcalcification: clustered pleomorphic

BSuspiciously Malignant Lesions1- Mass a-illdefined marginb- microlobulated c-increasing density

2-Architectural distortion

3-calcification a-micro/clusterdb- changing

CFindings may be associated with Ca1-Assymmetry a-tissue densityb- ductsc- veins

2-skin& trabecular thickening

3-Nipple retraction, deviation,inversion

4-Axillary LN enlarged-------------------------------------------------------------------------------------------------------A) Sure Malignant Lesions1) Malignant mass

• Dense mass with a spiculated margin• Irregular mass with a spiculated margin

DD a) Postsurgical scar• Looks different between the ML and CC projections while Ca looks the

same on bothb) Fat necrosis This pt had a biopsy with benign results 4yrs earlier. This spiculated mass with skin retraction proved to be fat necrosis.c) Radial scar Benign scarring process characterized by dramatic spiculation. It is idiopathic, unrelated to known trauma or surgery Excisional biopsy

---------------------------------------------------------------------------------------------2)Microcalcification

• A- Clusterd Microcalcification Def: 5 or more calcification each </= 0.5mm in a 1cc volume of breast tissue B- PleomorphicDef: Different in shape eg fine, linear,branching +irregular

2) Malignant MicrocalcificationsA) Clusters B) Pleomorphic:

1-Fine2-Linear3-Irregular4-Branching

---------------------------------------------------------------------------------------------• B) Suspicious Findings• 1) Lesions with illdefined margins Illdefinition: Common yet nonspecific characteristic that suggests a malignant process2) Lesion with microlobulated margins• Fibroadenoma may have a lobulated outline• The more lobulated the lesion, the more likely it is to be malignant i.e. when the lobulations are multiple and measure only several mm, the degree of suspicion should increase3) Architectural distortion• Ca does not always produce a mammographically visible mass.

• It frequently disrupt the natural tissue architectural distortion

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

DD: • Post surgical Scarring• Fat necrosis• Radial Scar4) Distorted Parenchymal edge• In the normal breast, the parenchymal cone interface is scalloped by Cooper’s

Ligament attaching by the retinacula cutis to the skin.• Ca developing at the edge distort this relationship and cause flattening,

retraction or bulging of the parenchyma in this region.

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

6) Clustered microcalcification• Def: 5 or more calcification each </= 0.5mm in a 1cc volume of breast tissue • DD: Benign secretory calcification= Plasma cell mastitis ® continuous thick

rods that do not branch, frequently bilateral7) Changing Calcification• As with masses, new microcalcification not present on previous mammogram

are of particular concern

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C) Findings that may be associated with Breast Cancer 1) Assymetric tissue density

• Asymmetric breast tissue differs from a focal asymmetric density• Focal asymmetry in the density of the tissues in one part of a breast relative to

its mirror image on the other side should be followed up.• The asymmetry is of greater significance when there is a corresponding

palpable abnormality on physical examination.2) Asymmetric ducts / 3)Asymmetric veins

• Considered normal variants unless associated with a palpable abnormality or other signs of Ca

4) Skin + Trabecular thickening

due to:

a) Direct invasion by Tu ® Tethering Cooper’s ligament Or

b) Obstruction of the lymphatic or venous return5) Nipple retraction, Deviation or Inversion

• As a 2ry sign of malignancy, nipple retraction is generally associated with large Ca .

• Other benign and congenital causes should be first excluded.6) Enlarged Axillary LN

• Causes:1- Benign hyperplasia2-Lymphoma3-Metastatic4-2ry breast malignancy----------------------------------------------------------------------------------------------------Take home Message…

Review clinical data and use US to help assess a palpable or mammographically detected mass.

Be strict about positioning and adequate technical aspects.

Requirements to optimize image quality.

Be alert to subtle features of breast cancers.

Compare current images with multiple prior studies to look for subtle increase in lesion size or density.

Look for other lesions when one abnormality is seen.

Judge a lesion by its most malignant features.

Double Reading.

Advanced Technology

Advances in Technology • WHAT IS IT ?• IS IT LUXURY ?

-----------------------------------------------------------------------------------• 1-Digital Mammography• 2- MR-Mammography

---------------------------------------------------------------------------------------There are 7 good reasons to go now for digital…

1. Superior in cancer detection.2. Reduction in ex. time, retakes and recalls.3. Improved Image quality and lesion detectability.4. Perfect analysis of microcalcification.5. High diagnostic accuracy.6. Dose reduction.7. Improve workflow with centricity solutions HIS / RIS

--------------------------------------------------------------------------------------------When to ask for MR-M?

1)Pre operative staging: To give additional pre operative information about:1- Tu size2- extensive intraductal component:3-Multifocality= 2 or more Ca within one breast quadrantIncidence 25%-50%4- Multicentricity= 1 or more Ca present in another quadrant than the one harbouring 1ry Ca with a minimum distance of 2 cmIncidence 15%-30%5- synchronous bilateral breast Ca----------------------------------------------------------------------------------------When to ask for MR-M?

----------------------------------------------------------------------------------------------------When to ask for MR-M?3) Metastases of unknown 1ry MR-M is indicated when mammo + US fail to identify intramammary 1ry4) Follow up after lumpectomy when mammo & US fail to solve the problem5) Differentiation between Scar & Ca

6) Follow up after lumpectomy when mammo & US fail to solve the problem7) Follow up after breast reconstruction with implant MR-M should be performed at regular intervals8) Prosthetic complicationsIntracapsular rupture ( 80-90% )-----------------------------------------------------------------------------------------------2- MR M

• Indications : • 1-Pre-operative a) Multicentricity• b) Bilaterality• c) Size / extent assessment• d) Multifocality• 2-Treatment Response• 3-Metastases of unknown 1ry• 4-Post-operative FU a) Post lumpectomy• b) Post implant

-----------------------------------------------------------------------------------------DON’T FORGET

• Suspicious Lesion ® Biopsy• The sure diagnosis always lie on the tip of the biopsy needle.• The safety and low morbidity of breast biopsy makes it difficult to be

postponed when a significant doubt exists.• Make advantage of the advances in Technology

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