8. Indications for mammography
• Screening asymptomatic women aged 50 years and over
• Screening asymptomatic women aged 35 years and over who have a high
risk of developing breast cancer:
women who have 1 or more first degree relatives diagnosed with
premenopausal breast cancer
women with histologic risk factors found at previous surgery, e.g. atypical
ductal hyperplasia
• Investigation of symptomatic women aged 35 years and over with a
breast lump or other clinical evidence of breast cancer
• Surveillance of breast following local excision of breast carcinoma
• Evaluation of a breast lump in women following augmentation
mammoplasty
• Investigation of a suspicious breast lump in a man.
9. Indications for ultrasonography
• Symptomatic breast lumps in women aged <35 years
• Breast lump developing during pregnancy or lactation
• Assessment of mammographic abnormality (± further mammographic
views)
• Assessment of MRI or scintimammography detected lesions
• Clinical breast mass with negative mammograms
• Breast inflammation
• The augmented breast (together with MRI)
• Breast lump in a male (together with mammography)
• Guidance of needle biopsy or localization
• Follow-up of breast cancer treated with adjuvant chemotherapy.
10. Triple assessment
• Clinical history and examination
• Imaging- mammography, ultrasonography
• Needle biopsy- FNAC or core biopsy.
11.
12.
13. • BIRADS 1 category: corresponds to normal tissues that cause clinical
abnormalities
• BIRADS 2 category: corresponds to benign entities and includes
intramammary lymph nodes, ectatic ducts, all simple and many
complicated cysts, and definitively benign solid nodules, such as
lipomas and hamartomas
• BIRADS 3 category: corresponds to “probably benign” lesions that
includes some complicated and complex cysts, small intraductal
papillomas, and a subset of fibroadenomas.
14. Breast composition
• A- Entirely fatty
• B- Scattered areas of fibroglandular density
• C- Heterogeneously dense, which may obscure masses
• D- Extremely dense, which lowers sensitivity.
15.
16. Circumscribed mass
A circumscribed mass is analysed according to the following features:
I. Opacity:
(i) radiolucent
(ii) mixed
(iii) radiopaque (soft-tissue opacity)
2. Contour:
• (i) sharply outlined
- capsule
- ‘halo’ sign
(ii) ill-defined outline
3. Interval change
4. Number: single or multiple.
20. Spiculate mass
• Consists of a central soft tissue tumour
mass from the surface of which
spicules extend into surrounding breast
tissue.
• D/D-
Invasive carcinoma
Non invasive carcinoma
Complex sclerosing lesion
Surgical scar
Fibromatosis
Granular cell tumour
21. • Straightening of trabeculae due to retraction; may cause
localised loss of the normal curvilinear outline of anterior or
posterior borders of glandular tissue close to tumour
resulting in a `V' shape-`tent' sign
• Localised skin thickening and retraction
• Tethering of pectoralis muscle
• Irregular microcalcifications within tumour or in surrounding
breast tissue.
23. Malignant vs Benign microcalcification
Feature Malignant Benign
Density and shape Variable Punctate or round; similar
density
Cluster shape Irregular or triangular,
pointing towards nipple
Round or oval
Distribution Within a lobe or segment
of breast
Often bilateral, or involves
multiple quadrants
24.
25. Miscellaneous calcifications
• Arterial: curvilinear, parallel line calcifications along course of a blood
vessel
• Skin: sebaceous gland, pseudoxanthoma elasticum, papilloma
• Fat necrosis: with a radiolucent centre
• Fibroadenoma: coarse ‘popcorn’ type calcification
• Cyst: curvilinear calcification
• Cavernous hemangioma: coarse and punctate calcification
26. • Calcified suture material
• Postsurgical scar
• Renal failure: extensive stromal calcification
• Breast augmentation:
Silicone implant- eggshell type calcification, may occur on surface
• Parasites: filariasis may cause single or multiple curvilinear or coiled
calcifications.
27.
28. Architectural distortion
• Numerous straight lines usually measuring 1-4 cm in
length, radiating toward a central area which
typically shows no central soft-tissue mass either on
standard or localised compression views.
• D/D-
Complex sclerosing lesion
Carcinoma
Surgical scar
29. • Common on normal mammograms- areas of low soft tissue opacity,
lucency and curvilinear margins with no evidence of straightened
breast trabeculae or distortion
• Some carcinomas, particularly small tumours
• Review areas:
I. 3-4 cm wide area anterior to edge of pectoralis muscle
II. Retroglandular clear space
III. Medial half of breast
IV. Retroareolar area
V. Inferior part of breast.
30. Edematous breast
• Thickened skin initially affecting mainly
lower part of breast
• Diffuse increased density
• Coarse trabecular pattern
• Enlargement of breast
• D/D-
Primary breast carcinoma
Axillary lymph node metastases
Breast abscess
CCF and renal failure
Radiotherapy
43. Fibroadenoma
• Mammography-
Characteristically sharply outlined
Low soft tissue opacity
Sometimes with a lobulated outline
Usually solitary but may be multiple
With increasing age, may undergo
calcification which is typically coarse;
eventually an area of dense
calcification with little evidence of a
soft-tissue mass
44. • USG-
Well circumscribed round or
oval mass
Showing posterior acoustic
enhancement
With a homogeneous internal
echo pattern, usually of low
reflectivity
Posterior acoustic shadowing
and a heterogeneous internal
echo pattern are frequent with
or without associated
calcification.
45. Phyllodes tumour
• Mammography:
Typically non-specific large rounded oval
or lobulated, generally well circumscribed,
with smooth margin
A radiolucent halo may be present
Calcification (typically coarse and plaque
like) may be seen in a very small
proportion
46. • USG:
Non-specific and can mimic that
of a fibroadenoma
An inhomogeneous, solid-
appearing mass containing single
or multiple, round or cleft like
cystic spaces and demonstrating
posterior acoustic enhancement
Vascularisation is usually
present in solid components.
47. Simple cyst
• Most commonly 1-3 cm in
diameter
• Often multiple and bilateral
• Round or oval echo-free lesion
with smooth, well-defined walls
and posterior acoustic
enhancement.
48. Complicated cysts
• Contain echogenic fluid, fluid-
debris levels, or fat-fluid levels
• Generally benign, at low risk of
containing papillomas or
carcinomas
• Part of broad spectrum of
benign fibrocystic change (FCC).
49.
50. Complex cyst
• Thick and irregular walls, mural
nodules, thick septations, and
internal blood flow
• Increased risk of containing
papillomas or carcinomas.
51.
52. Evaluation of nipple discharge
• High-risk discharge:
Unilateral, spontaneous, from a
single duct orifice, and clear,
serous, serosanguineous, or
frankly bloody
Often caused by papillomas or
carcinoma
Galactography is practical
• Low-risk discharge:
Bilateral, from multiple duct
orifices, expressible rather than
spontaneous, and milky or
greenish in color
Usually caused by fibrocystic
change or duct ectasia
USG is practical
64. Role of Doppler ultrasonography
• Differentiating benign from malignant solid nodules
• Assessing aggressiveness of solid nodules
• Diagnosing vascular conditions such as arteriovenous
malformations, arteriovenous fistulas, venous
malformations, and superficial venous thrombosis (Mondor’s
disease)
65. • Distinguishing between reactive or inflamed lymph nodes
and metastasis-bearing nodes
• Differentiating complicated cyst from pseudocystic solid
nodule
• Differentiating inflammatory and neoplastic causes of duct
ectasia
• Avoiding vascular structures during interventional
procedures.
66. Indications for MRI
• Technique of choice in differentiation between postoperative scarring
and local recurrence
• Assessment of indeterminate mass; very accurate in local staging of
breast cancer in difficult cases (very dense breasts,
mammographically occult tumours, suspected multifocality or
multicentricity and suspected chest wall involvement)
• Technique of choice in detection of cancer in augmented breast
• Differentiation of axillary recurrence and brachial plexopathy post
radiotherapy- accurate
• Assessment of response to neoadjuvant and primary chemotherapy,
and differentiating between residual tumour and fibrosis- highly
accurate.
