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Approach to mammogram
The document provides a detailed overview of breast anatomy and its imaging characteristics as seen in mammograms, categorized by the BI-RADS system. It describes the zonal anatomy of the breast, types of breast composition, and interpretations of mammographic findings, including benign and suspicious characteristics. The importance of assessing various factors such as mass shape, margins, and calcification types to evaluate anomalies and potential malignancy risk is emphasized.
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Approach to mammogram
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- 2. General breast anatomy •Conical, round or hemispherical shape • Comprised of 15-20 lobes, each encased in fascial sheath defined by AMF & PMF • Extends from 2nd or 3rd intercostal space to 6th or 7th intercostal space • Extends laterally to anterior axillary fold and medially to lateral sternum • Relationship to chest wall • Superior two-thirds overlies pectoralis major muscle • Lateral portions overly serratus anterior muscle • Inferior-most margin overlies upper abdominaloblique muscles • Axillary tail of Spence: Extension of normal breast • tissue toward axilla
- 3. ZONAL ANATOMY • Premammary(Subcutaneous) Zone • Most superficial zone • Anterior margin defined by skin, posterior margin defined by AMF • Contains subcutaneous fat, blood vessels, anteriorsuspensory (Cooper) ligaments • May contain ectopic ducts and TDLUs ASLs(Cooper ligaments) • Formed from two leaflets of AMF inserting into dermis • Provide support for breast • Usually visible on mammograms and sonograms
- 4. • Mammary Zone •Defined anteriorly by AMF and posteriorly by PMF • Contains majority of ducts/TDLUs, stromal fat and stromal connective tissue • Subdivided haphazardly by interspersed ASLs. • Retromammary Zone • Most posterior of three zones • Defined anteriorly by PMF and posteriorly by chest wall • Contains fat and PSLs which attach PMF to chest wall
- 6. BI-RADS BREAST COMPOSITION •The American College of Radiology Breast Imaging and Reporting Database System (BIRADS)divides breast composition into four categories: • 1) almost entirely fat, • 2) scattered fibroglandular densities (approximately 25-50% glandular), • 3) heterogeneously dense (51-75% glandular), • 4) extremely dense (greater than 75% glandular).
- 12. BIRADS INFERENCE 0 Needs additional imaging evaluation 1 2 RISKOF MALIG. Negative/ Normal Benign Findings. •Fat containing. •Benign Intramammary LN •Benign Calcifications No further evaluation needed 3 Probably Benign. Short term Follow up is suggested TYPICAL EXAMPLES =< 2 % Round, oval or lobulated lesion with circumscribed margins.
- 13. 4 Suspicious Abnormality. 3 – 94% Biopsy should be considered 5 6 Highly suggestive of malignancy Appropriate intervention to be taken Biopsy proven Malignancy > 95% Irregular shaped, spiculated margins.
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- 17. SOL seen intwo different projections and have convex borders. 1. SIZE 2. SHAPE 3. MARGINS 4. DENSITY 5. CALCIFICATION
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- 22. DENSITY High Iso Low ( not fat) Fat containing Oil cysts Lipoma Galactocele Hamartomas Fibroadenolipomas
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- 27. MORPHOLOGY: Benign Skin Calcification VascularCalcification Popcorn Calcification Rod like Calcification Lucent Centered Deposits Eggshell/ Rim Calcification Precipitated Calcification in milk of calcium. Large Dystrophic Calcification
- 28. Skin Calcification Tattoo Sign Usuallylocated along inframammary fold parasternally, axilla and areola. Can be seen in the skin which is enface
- 29. Vascular Calcification Linear orparallel tracks that are usually clearly associated with blood vessels.
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- 31. Rod like calcification Withinectatic ducts due to secretory deposits and follow ductal distribution radiating towards nipple. May be continuous or discontinuous and may show branching. Differentiate from malignant fine branching calcifications.
- 32. Lucent centered deposits FatNecrosis Calcified Debris in ducts Occasionally in Fibroadenoms
- 33. Eggshell or RimCalcification Wall of the Cyst. Fat Necrosis. Periphery of Fibroadenoma
- 34. Milk of Calcium Arebenign sedimented calcification in macro or micro cysts. Typical feature is apparent change in shape on different projections.
- 35. • Whenever thereis possibility of milk of calcium consider magnification medio-lateral spot film
- 36. Dystrophic Calcification Coarse irregularlava shaped calcification. In irradiated breast or following trauma
- 37. Round calcification >0.5 mm. Infibrocystic changes or adenosis or skin calcification.
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- 39. Amorphous or indistictcalcification Calcification without a clearly defined shape or form. They are usually so small or hazy in appearance, that a more specific morphologic classification can not be determined. Present in many benign and malignant breast diseases. About 20% of amorphous calcifications turns out to be malignant.
- 40. Coarse Heterogenous Irregular calcification thatare usually larger than 0.5 mm but not the size of large heterogenous dystrophic calcifications.
- 41. MORPHOLOGY: High Probabilityof Malignancy Fine Pleomorphic: < 0.5 mm Variable in size, density or form 25 – 40% risk of malignancy
- 42. Fine Linear orBranching < 0.5mm in width. Linear or branching distribution
- 43. • As comparedto Malignant Calcification, Benign Calcifications are: – Larger – Coarser – Round and smooth – Easily seen.
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- 45. • In contrastto a mass, which is a 3-D structure demonstrating convex outward borders and which is usually evident on two orthogonal views, asymmetric findings lack the convex outward borders and the conspicuity typical of a mass.
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- 48. ASYMMETRY • If apotential mass is seen in only a single view at standard mammography, it should be called an “asymmetry” until its three-dimensionality is confirmed. • Approximately 80% of cases are due to summation shadow, of normal fibroglandular breast. • True lesions may sometimes appear on only one view because on other views they are either obscured by overlapping dense parenchyma or are located outside the field of view.
- 50. GLOBAL ASYMMETRY • Isseen in both the views. • Involves a greater volume of breast tissue (at least a quadrant) • Without any associated mass, suspicious calcifications, or architectural distortions. • It is usually due to normal variations or hormonal influence and only significant when it corresponds to a palpable abnormality.
- 52. FOCAL ASYMMETRY • Isseen in both the views. • Involves a less than one quadrant of breast. • It can be due to normal variations or some lesion.
- 54. DEVELOPING ASYMMETRY • Thisis a focal asymmetry that is new, larger, or denser at current examination than at previous examinations.
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- 57. BENIGN INTRAMAMMARY LYMPHNODE • Well circumscribed. • < 1cm • UPPER AND OUTER QUADRANT • Lucent and invaginated fatty hilum • May appear as 3 or more round densities in horse shoe arrangement.
- 58. When not toconsider Benign Intramammary node • If a mass is seen in a section other than upper and outer quadrant, unless it has a clearly defined hilum. • Lesion in upper outer quadrant does not have other characteristics, it should be considered suspicious as malignant node or primary mass.
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- 60. • Tubular or branching structure representing dilatedduct. • Usually of minor significance. • BIRADS III
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- 62. • Spiculations radiating froma point without any identifiable mass. • The only architectural distortion that does not require further evaluation is that caused by prior surgery or trauma. • BIRADS IV
- 67. SKIN RETRACTION NIPPLE RETRACTION SKIN THICKENING TRABECULAR THICKENING AXILLARY LYMPHADENOPATHY
- 68. • FINALLY WEHAVE to decide on the significance of the mammographic findings. • FINALISE THE REPORT IN 7 SPECIFIC CATEGORIES.
Editor's Notes
- #27 Morphology is the most imp descriptor for calcification and the risk associated with diff types of morphology is stratifies into groups……
- #32 , as are usually > 1mm in diameter and diffusely distributed
- #34 very thin benign calcifications that appear as calcium deposited on the surface of a sphere.
- #46 BIRADS defines it as
- #47 The mass isseen as a space-occupying structure with convex outward borders (arrows).Figure 2: Asymmetry seen in (a) schematic, (b) MLO views, and (c) CC views. Apotential lesion lacking the characteristics of a mass is seen only on the left CC view(arrow). A corresponding abnormality is not seen on the left MLO view.
- #49 So perform additional views.LESION SHOULD NOT BE IN THE AREA WHICH CANT BE CAPTURED IN BOTH THE VIEWS LIKE IN AXILLA NEAR CHEST WALL.For an asymmetry seen only on the MLO view, it is frequently best to go immediatelyto the straight lateral view (8). This slight shift in the orientation of breast structuresrelative to the x-ray beam is often sufficient, by the disappearance or changedFor asymmetries seen only on CC projections, the rolled view is best for determiningthe presence of a lesion (8). To obtain this view, the breast can be gently rotated aroundthe axis of the nipple and recompressed in this new orientation. Rolling the breast willdo little to obscure a true lesion, which will simply be displaced in the direction of theapplied roll. Conversely, rolling the breast in an appropriate manner will cause asummation shadow to virtually disappear because the relevant tissues will be displacedwith regard to one another. To properly determine the presence of a lesion, the directionof roll should be chosen so that the region in question is rolled toward and projectedover an area of fat and not over dense tissue, so that the lesion is not obscured. Thisrequires preliminary assessment of the fibroglandular pattern. If a true lesion is rolledinto an area of dense fibroglandular tissue, it may be obscured, leading to the erroneousconclusion that it has "disappeared." Therefore, each rolled projection must be tailoredfor each patient (7). In addition, movement of a true abnormality relative to theSpot Compression View
- #50 Figure 2: Asymmetry seen in (a) schematic, (b) MLO views, and (c) CC views. Apotential lesion lacking the characteristics of a mass is seen only on the left CC view(arrow). A corresponding abnormality is not seen on the left MLO view.
- #52 Figure 3: Global asymmetry seen in (a) schematic, (b) MLO views, and (c) CCviews. A much greater volume of breast tissue is seen over a substantial portion of theleft breast relative to the corresponding region in the right breast, but there is noassociated mass, suspicious calcifications, or architectural distortion.
- #54 Figure 4: Focal asymmetry seen in (a) schematic, (b) MLO views, and (c) CC views.A focal asymmetry with a similar shape (arrows), not fitting the criteria of a mass, isseen on two standard views.Developing AsymmetryThis is a focal asymmetry that is new, larger, or denser at current examination thanat previous examinations (Fig 5). To identify such a lesion, comparison with previousmammograms is critical. It raises a reasonable degree of suspicion and requiresadditional evaluation in the absence of a history of hormonal therapy, surgery, trauma,or infection at the site. It is an uncommon mammographic finding, reported in less than1% of examinations, but the likelihood of malignancy ranges from 13% to 27% (Fig 6)(4).5a.10
- #55 HOW TO DIFFRENTIATE ASYMMETRY FROM FOCAL ASYMMETERY- ARC METHOD AND LINE METHOD…….. ASDESCRIB ED IN ARTICLE
- #56 Can be kept in BIRADS II or III ( if radiologists feel it to be followed up)?If palpable abnormality is present at same site BIRADS IV
- #69 Not the single desriptor which will help us decide BIRADS but the constillation of findings……. There is no strict criteria for certain things to assign BIRADS and it depend on radiologidt what degree of suspicion he has…………. So although BIRADS has been standarised to a great extent but stilllSubjectiveness remains in classifyng lesions…..