The quality of the mammograms should be
assessed, and if not optimal, repeat
examinations may be ordered.
Mammograms of the right and left breasts
are first placed back to back (mirror images)
for comparable projections.
Lighting should be homogeneous, and
adequate viewing conditions should be
maintained. The mammograms are inspected
carefully. The search is done systematically
through similar areas in both breasts.
First, breast symmetry, size, general
density, and glandular distribution are
observed. Next, a search for
masses, densities, calcifications, architectural
distortions, and associated findings is
Benign calcifications tend to have specific
shapes: eggshell calcifications in cyst
walls, tramlike in arterial walls, popcorn type
in fibroadenomas, large and rodlike with
possible branching in ectatic ducts, and small
calcifications with a lucent center in the skin.
Associated findings are then taken into account.
These include skin or nipple retraction, skin
thickening (which may be focal or diffuse)
especially with superficially positioned
lesions, tethering of the pectoralis major may be
seen with deeply positioned tumors, trabecular
thickening, skin lesions, axillary adenopathy, and
If previous examination results are
available, their comparison is useful in assessing
The lesion seen is located by using the views
to either of the inner or outer or the lower or
upper quadrants. It may also be central or
retroareolar. The lesion can be described in a
clock-shape position. The breast is viewed as
the face of a clock with the patient facing the
observer. The depth of the lesion is assigned
to the anterior, middle, or posterior third of
Masses in adipose breasts are east to detect
because of the high contrast between the
mass and surrounding breast tissue. In dense
glandular breasts, masses can be difficult to
perceive because they may be partially
obscured by glandular tissue.
A 'Mass' is a space occupying lesion seen in two
different projections. If a potential mass is seen in
only a single projection it should be called a 'Density'
until its three-dimensionality is confirmed.
Circumscribed (well-defined or sharply-defined)
margins: The margins are sharply demarcated with an
abrupt transition between the lesion and the
surrounding tissue. Without additional modifiers
there is nothing to suggest infiltration.
Indistinct (ill defined) margins: The poor definition of
the margins raises concern that there may be
infiltration by the lesion and this is not likely due to
superimposed normal breast tissue.
Spiculated Margins: The lesion is characterized by
lines radiating from the margins of a mass.
The normal architecture is distorted with no
definite mass visible. This includes
spiculations radiating from a point, and focal
retraction or distortion of the edge of the
parenchyma. Architectural distortion can also
be an associated finding.
This is a density that cannot be accurately
described using the other shapes.
It is visible as asymmetry of tissue density with
similar shape on two views, but completely
lacking borders and the conspicuity of a true
It could represent an island of normal breast, but
its lack of specific benign characteristics may
warrant further evaluation.
Additional imaging may reveal a true mass or
significant architectural distortion.
Due to confusion of the term mass with the term
'density' which describes attenuation
characteristics of masses, the term 'density' has
been replaced with 'asymmetry'.
A spiculate breast mass is the commonest
mammographic appearance of invasive breast
It consists of a central soft tissue tumor mass
from the surface of which spicules extend
into the surrounding breast tissue. The larger
the tumor mass, the larger the spicules tend
Invasive carcinoma: 95% of spiculate masses
seen on mammography
Non invasive carcinoma
Complex sclerosing lesion/ radial scar
Granular cell tumor
Characterized histologically by a fibroelastic
centre surrounded by ducts and lobules
arranged in a radiating fashion.
Areas of similar or atypical ductal hyperplasia
are often found in the peripheral of CSLs.
Microcalicifications may be associated
particularly in areas of epithelial hyperplasia.
Usually diagnosed with ease from the
appropriate clinical history and physical
examination revealing the position of scar
corresponding to the spiculated lesion.
In cases of confusion may be confirmed by
repeating the mammogram with skin markers
placed on the scar.
Surgical scars often show a difference in size
and shape on orthogonal views cause of their
They are histologically similar to abdominal
They are locally invasive but do not
Most Ca greater than 1 cm can be reliably
demonstrated by ultrasound.
Typical features are echo poor mass, with
poorly defined margins and posterior
There may be distortion of the surrounding
parenchyma and a rim of increased
reflectivity may be seen- tumor collar
SHAPE Oval/ellipsoid Variable
Wider than deep, aligned
parallel to tissue planes
Deeper than wide
pseudocapsule with 2-3
Irregular or spiculated,
Variable to intense
HOMOGENETY OF INTERNAL ECHOES Uniform Non uniform
LATERAL SHADOWING Present Absent
across tissue planes and
increased echogenecity of
BI-RADS assessment categories can be
summarized as follows:
Category 0 - Need additional imaging evaluation
Category 1 - Negative
Category 2 - Benign finding, noncancerous
Category 3 - Probably benign finding, short-
interval follow-up suggested
Category 4 - Suspicious abnormality, biopsy
Category 5 - Highly suggestive of malignancy,
appropriate action needed
Category 0 is a temporary category that means
additional imaging is needed before assigning a
permanent BI-RADS assessment category.
Left breast MLO view screening
mammograms shows a spiculated
mass in the posterior mid to upper