This document summarizes various breast imaging modalities. It discusses the role of mammography, ultrasound, MRI, PET, and other techniques in evaluating the breast. Mammography remains the primary screening tool but has limitations related to breast density. Ultrasound helps diagnose palpable lesions and differentiate cysts from solid masses. MRI detects additional cancers but has limitations of cost and availability. Combined modalities provide improved evaluation of the breast compared to single techniques alone.

1. MODERATOR- PROF DR YASHPAL
RAMOLE(M.Ch)
PRESENTOR- DR ABHISHEK

2.  Imaging plays an important role in breast evaluation
– symptomatic , asymptomatic and high risk cases,
screening.
 In diagnosed cases of breast cancer it helps in
staging , monitoring , the response therapy and in
post treatment follow up
 It reliably differentiates between malignant and
benign breast lesions.
 No screening tool is 100 % accurate.

3.  MAMMOGRAPHY
 ULTRASOUND
 MRI
 PET

4.  It is the use of low voltage x rays to image breast.
 It has a sensitivity of 75 to 80 % and specificity of
90 to 95 %.
 Randomized, population- controlled breast cancer
screening trials using mammography have shown an
approximately 30% reduction in breast cancer
deaths in the women invited to screening compared
to women in the control group.
 American Cancer Society recommends annual
screening mammography for women age 40 years
and older.

5.  Screening mammography – refers to imaging of
asymptomatic women for detection of breast cancer
at early and potentially curable stage using the
standard craniocaudal and mediolateral oblique
views of each breast
 Diagnostic mammography – evaluation of
symptomatic patients or those recalled from
screening because of abnormal or specific
mammographic findings, includes spot compression
or magnification views.

6. MAMMOGRAPHY VIEWS
• Craniocaudal CC
• Mediolateral oblique MLO
• Mediolateral ML
• Lateral-medial LM
• Laterally exaggerated craniocaudal XCCL
• Medially exaggerated craniocaudal XCCM
• Cleavage view CV
• Rolled view laterally RL
• Rolled view medially RM

7. Views Used to Confirm or Exclude a Lesion
 Lateral view
 Spot compression
 Spot compression magnification
 Rolled views (with or without spot compression or
magnification)
 Repeat the same view
 Step oblique views

13. Mammography - Breast Imaging Lexicon
 Breast Composition
 Mass
 Architectural distortion
 Asymmetries
 Calcifications
 Associated features
 Special cases

14. BREAST COMPOSITION
 In the BI-RADS edition 2013 the assignment of the
breast composition is changed into a, b, c and d-
categories followed by a description:
 a- The breast are almost entirely fatty. Mammography is
highly sensitive in this setting.
 b- There are scattered areas of fibroglandular density.
 The term density describes the degree of x-ray
attenuation of breast tissue but not discrete
mammographic findings.
 c- The breasts are heterogeneously dense, which may
obscure small masses. Some areas in the breasts are
sufficiently dense to obscure small masses.
 d- The breasts are extremely dense, which lowers the
sensitivity of mammography.

15.  ASYMMETRY – soft tissue finding seen only in one
view, without matching tissue in a similar location in the
contralateral breast
 Focal asymmetry - soft tissue finding seen on two
projections lying at comparable depth
 Masses – 3 dimensional space occupying lesion with
consistent convex margin
 Oval masses are likely benign, irregular masses are
likely malignant
 High density masses are suspicious low density/fat
density are almost always benign
 Benign calcifications are – skin, vascular, popcorn ,
eggshell, fat necrosis
 Amorphous, coarse heterogenous , fine pleomorphic
calcifications , linear / fine branching calcifications are
more suspicious of malignancy.

25.  BI-RADS® is designed to standardize breast
imaging reporting and to reduce confusion in breast
imaging interpretations.
 It also facilitates outcome monitoring and quality
assessment.
 It contains a lexicon for standardized terminology
(descriptors) for mammography, breast US and
MRI.
 All mammographic, ultrasound, and breast MRI
findings and reports should closely adhere to the BI-
RADS lexicon and assessment categories.

28.  Sensitivity decreases significantly in denser breast.
 Tissue superimposition in dense breast
 Mammogram involves compressing breast between
two plates which causes overlapping of tissue and is
uncomfortable to some patients.
 It has high false positive and false negative rates
upto 20 %

29.  Ultrasound is a useful adjunct to mammography for the
diagnosis and management of benign and malignant
breast disease.
 Hand-held units should include a linear array, high-
frequency transducer operating at a frequency of 7.5 to
10 mhz or greater, which provides good tissue
penetration to 4 or 5 cm
 It should not be used as a sole modality for screening as
ultrasound does not always detect cancers that are
visualised mammographically.
 Can detect clinically and mammographically occult
cancers particularly when there is a higher possibility of
cancer.

30. INDICATIONS
 Effective tool for detection of masses in dense breast
 Primary modality for evaluation of palpable lesion in
young patients
 Useful in denser breast, pathological nipple discharge,
intraductal papilloma.
 Differentiate cystic versus solid lesion.
 Guided needle biopsy
 Breast lump in pregnancy and lactation
 Symptomatic breast diseases in women age less than 35
years

35.  Anechoic cyst – no internal echoes and most commonly not
always is a simple cyst
 Hypoechoic structure – low level attenuation suggestive of
complicated cyst or fibroadenoma.
 Complex echo pattern – complex mass or necrotic tumor
 Acoustic posterior enhancement – simple cyst
 Ultrasound features of benign lesion –
 Marked hyperechogenecity
 Ellipsoid shape
 Circumscribed margins
 Parellel orientation to skin
 Thin pseudocapsule

36.  Posterior shadowing
 Spiculated margins
 Hypoechoic texture
 non parellel
 Calcifications
 Microlobulated margins

37. Benign Characteristics
Ellipsoid shape
Thin definable
capsule
Two or three
lobulations
Hyperechogenicity

38. Solid Mass -
Malignant
• Irregular shape
• Irregular/ill-defined
borders
• Almost anechoic
• Angular margin
• Taller than wide

39.  Multifocality
 Multicentricity
 Invasion of fascia in patients with invasive carcinoma
and ductal carcinoma in situ
 Screening of contralateral breast
 Screening women with high risk of breast malignancy
wiz strong family history, radiation exposure history,
genetic predisposition
 Recurrent breast cancer
 Study of breast with breast implants integrity in follow
up

40.  MRI is not a substitute to mammography or biopsy
 Lack of contrast enhancement has high negative
predictive value for malignancy.
 LIMITATIONS –
 Cost restraints
 Claustrophobia
 Cant be used in metallic implants

41. Signals from Water:
 tissues with a long T2 are presented as bright signals on T2-
weighted images. Thus, cysts (that contain fluid) with long T1 are
dark on T1-weighted images and those with long T2 are bright on
T2-weighted images.
On MRI this cyst had a characteristically low signal intensity
(black) on this T1-weighted image (A) and a high signal
intensity (white) on the T2-weighted image (B).

42. Breast cancers are usually irregular in shape
and heterogeneous in their enhancement on
MRI.

43.  Detects angiogenesis associated with lesions
 Two types – digital substraction
mammography ( DSM ) – in which a single
view image of single breast is acquired before
and after contrast injection
 Contrast enhanced spectral mammography
(dual energy mammography )

44.  Detects abnormal metabolic activity of various
organs
 Diagnosis , staging and restaging
 Detection and localization of metastasis
 Monitoring treatment response
 Early detection of recurrence
 Localizing primary tumor with metastasis in case of
indeterminate usg or mammogram

45.  Noninvasive technique
 Measure changes in temperature overlying skin over
breast lesions
 Images are displayed as color patterns
 Can be contact or telethermography
 Newer technique not gained much accpetance.

46.  Using ultrasound, elastography shows cancers,
which are generally stiffer than normal soft breast
tissue, as darker and larger than on the B-mode
gray-scale ultrasound.
 Benign masses are soft and less stiff than cancers.
 The elastogram shows benign masses as smaller on
elastography than on B-mode grayscale images

47.  It is a technique used to produce 3 d images from 2
d scans using 360 degree x ray arc
 Minimizes the radiation exposure
 Corrects drawbacks of mammography like
overlapping, compression of breast uncomfortable
to women
 Only approved in european union