This document provides an overview of breast lesions and their evaluation using mammography and ultrasonography. It describes the appearance and characteristics of common benign and malignant breast lesions seen on imaging. Key points include: 1. It outlines the triple assessment approach to evaluating breast lesions involving clinical examination, imaging with mammography and ultrasound, and needle biopsy when needed. 2. Common benign lesions seen on imaging include fibroadenomas, simple cysts, and phyllodes tumors, while malignant lesions can present as spiculated or angular masses, architectural distortion, or microcalcifications. 3. Imaging findings that suggest malignancy include an irregular shape, angular margins, acoustic shadowing, hypoechogenicity, and

1. APPROACH TO BREAST
LESIONS- MAMMOGRAPHY
AND ULTRASONOGRAPHY
Dr Mahin Binte Anwar
Phase- B Resident
Department of Radiology and Imaging, BSMMU

3. Lesions affecting breast
• Developmental/ normal
variants:
1. Supernumerary nipples or
breasts
2. Accessory axillary breast tissue
3. Congenital nipple inversion
4. Macromastia
5. Congenital absence or
hyperplasia of pectoralis
muscle
• ANDIs:
1. Duct ectasia
2. Fibrocystic change
3. Benign proliferative disorders-
i. Epithelial hyperplasia
ii. Sclerosing adenosis
iii. Complex sclerosing lesion

4. • Inflammations:
1. Acute mastitis
2. Periductal mastitis
3. Fat necrosis
4. Lymphocytic mastopathy/
sclerosing lymphocytic
lobulitis
5. Granulomatous mastitis
• Benign epithelial tumours:
Papilloma
• Benign stromal tumours:
1. Fibroadenoma
2. Lipoma
3. Hamartoma
4. Fibromatosis
5. Phyllodes tumour
• Benign proliferative breast
diseases with atypia:
1. Atypical ductal hyperplasia
2. Atypical lobular hyperplasia

5. • Malignant:
1. Carcinomas
I. In situ- DCIS, LCIS
II. Invasive- Ductal, Lobular,
Tubular, Mucinous, Medullary,
Papillary, Metaplastic
2. Sarcomas- Angiosarcoma,
Rhabdomyosarcoma,
Liposarcoma,
Leiomyosarcoma,
Chondrosarcoma,
Osteosarcoma
3. Others-
I. Skin, sweat glands, sebaceous
glands, hair shafts
II. Lymphomas
III. Metastases- contralateral
breast carcinomas,
melanomas, lung cancers

6. Common complaints
• Palpable lump
• Nipple discharge
• Pain
• Others- deformities, generalized swelling, palpable axillary
lymph nodes

7. Imaging modalities
• Mammography
• Ultrasonography
• MRI
• Tomosynthesis
• Scintimammography
• Galactography

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.

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.

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.

17. Radiolucent lesions- D/D
• Lipoma
• Oil cyst
• Galactocele

18. Mixed lesions- D/D
• Adenolipoma/ hamartoma
• Galactocele
• Hematoma
• Lymph node

19. Radiopaque lesions- D/D
• Benign lesions:
Cyst
Fibroadenoma
Papilloma
Phyllodes tumour
Abscess
Lymph node- rheumatoid arthritis,
sarcoidosis
Sebaceous cyst
• Malignant lesions:
Mucinous carcinoma
Medullary carcinoma
Papillary carcinoma
Invasive ductal carcinoma
DCIS-intracystic carcinoma
Metastasis- melanoma, lung, ovary
Lymphoma
Sarcoma
Pathological lymph node- breast cancer, phyllodes
tumour, lymphoma, metastasis
Recurrent breast cancer

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.

22. Microcalcifications
• D/D:
Ductal carcinoma in situ
Sclerosing adenosis/fibrocystic change
Atypical ductal hyperplasia
Simple epithelial hyperplasia
Microcystic change
Fibroadenoma
Papilloma

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

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.

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

31. Mammographic-sonographic correlation
• Size Correlation
• Shape Correlation
• Location or Position Correlation
• Surrounding Tissue Density Correlation

33. • Hard findings:
Spiculation (halo)
Angular margins
Acoustic shadowing
• Mixed findings:
Hypoechogenicity
Taller than wide
• Soft findings:
Microlobulation
Duct extension
Branch pattern
Microcalcifications

34. Typical USG characteristics of solid lesions
Features Benign Malignant
Shape Oval/ ellipsoid Variable
Alignment Wider than deep; aligned parallel to
tissue planes
Deeper than wide
Margins Smooth/ thin echogenic
pseudocapsule with 2-3 gentle
lobulations
Irregular/ spiculated; echogenic halo
Echotexture Variable to intense hyperechogenicity • Low level
• Marked hypoechogenicity
Homogeneity of internal echoes Uniform Non- uniform
Lateral shadowing Present Absent
Posterior effect Minimum attenuation/ posterior
enhancement
Attenuation with obscured posterior margin
Other signs • Calcification
• Microlobulation
• Intraductal extension
• Infiltration across tissue planes and increased
echogenicity of surrounding fat

35. Spiculation or Thick Echogenic Halo

36. Angular Margins

37. Microlobulations

38. Taller than wide shape

39. Duct extension and branch pattern

40. Acoustic shadowing

41. Calcifications

42. Hypoechogenicity

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).

50. Complex cyst
• Thick and irregular walls, mural
nodules, thick septations, and
internal blood flow
• Increased risk of containing
papillomas or carcinomas.

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

56. Regional lymph node assessment

57. • Metastatic node:
Eccentric cortical thickening-
hallmark
Abnormally hypoechoic cortex
Obliteration of hilum
Microcalcifications
Abnormally round shape
Minimum diameter>1cm
• Reactive node:
Symmetrical cortical thickening
(3 mm or more)
Similar findings in adjacent
nodes

60. Implants

61. Radial folds

62. Intracapsular rupture

63. Extracapsular rupture

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.

67. THANK YOU