IMAGING MODALITIES

Provides information that

o Confirms finding
o On conditions not previously noted
MAMMOGRAPHY
Designed to recognize early signs of malignancy
before they become clinically manifested
o Even before a mass becomes palpable
Provides detailed images of internal structures
o Demonstrate microcalcifications
Used for screening and diagnostic purposes
Most common abnormalities seen on mammogram:
o Dominant masses
Size and regularity of the margins of masses
differentiates benign from malignant potential
Speculated lesion is most likely malignant
Smooth, round mass may be a cyst or
fibroadenoma
o Microcalcifications
Benign: characterized by diffuse scattering
and crescentric tea-cupping
Malignant:
characterized
by
isolated
clusters, punctate of varying sizes, and a
branching or linear pattern
Accuracy and sensitivity of mammograms
o It has positive and false negative results
o Missed breast cancers occur (due to)
Dense parenchyma
Poor technique or positioning
Incorrect interpretation
Slow growth of malignancy
o The false negative rate of mammography is about
8-10%
Negative
mammogram
and
sonogram,
approximately 1-3% of patients with a clinically
suspicious abnormality may still have breast
cancer
o The positive predictive value can be as low as 10%
in some cases, demonstrating the need for
additional imaging modalities, such as ultrasound
Conventional Mammography
o Delivers a radiation dose of 0.1 cGy per study
o VS chest radiography (25% of this dose)
o No increased breast cancer risk
Screening Mammography
o For screening purposes:
2-view mammography (craniocaudal, CC and
mediolateral oblique, MLO) has become the
method of choice
Mammography is recommended every 1-2
years for women >40 yo, and annually for >50
yo
o Highly sensitive tool but sensitivity is reduced in
younger women with denser breasts
Therefore,
screening mammography is
considered inappropriate in patients <35 yo
Exemption: use mammography in patients
>30 yo when classified as high risk for
malignancy
o Used to detect unexpected breast cancer in

Provides better visualization of the

medial aspect of the breast and permits
greater breast compression

2. Mediolateral Oblique (MLO)

Images the greatest volume of breast
tissue, including upper outer quadrant
and the axillary tail of Spence

Diagnostic Mammography
o Used to evaluate exact size and location of an
abnormality as well as to image the surrounding
tissue and lymph nodes
o Standard CC and MLO + additional angles and
magnified views of suspicious areas may be taken
and interpreted
o Used to evaluate women with abnormal findings
such as a breast mass or nipple discharge
o In addition to the MLO and CC views, a diagnostic

Transcribers:
Page 1 of 4

 Spot compression view

- May be done in any projection by using a
small compression device, which is placed
directly over a mammographic abnormality
that is obscured by overlying tissues
- The compression device minimizes motion
artifact, improves definition, separates
overlying tissues, and decreases the
radiation needed
- Often
combined
with
magnification
techniques
(x1.5)
to
better
resolve
calcifications and the margins of the
masses

Mammography also is used to guide interventional

procedures
o Needle localization
o Needle biopsy
Specific mammographic features that suggest a
diagnosis of breast cancer
o Solid mass with or without stellate features
o Asymmetric thickening of breast tissues
o Clustered microcalcifications
The presence of fine, stippled calcium in and
around a suspicious lesion is suggestive of
breast cancer
Esp important sign of cancer in younger
women, in whom it may be the only
mammographic abnormality
Mammography was more accurate than clinical
examination for the detection of early breast cancers
Normal-risk women 20 years of age should
have a breast examination at least every 3 years
Starting at age 40 years, breast examination should
be performed yearly and a yearly mammogram
should be taken
The use of screening mammography in women <50
yo is more controversial:
o reduced sensitivity
o reduced specificity
o lower incidence of breast cancer
Screen
film
mammography
has
replaced
xeromammography
o Requires a lower dose of radiation and provides
similar image quality
Digital Mammography
o Allow observer to manipulate the degree of
contrast in the image
Useful in women with dense breasts, women
<50 yo, premenopausal or perimenopausal
wome (more accurate)
The use of digital breast tomosynthesis with 3D
images has been introduced as an alternative to
standard 2D mammography imaging that is
limited by superimposition of breast parenchyma and
breast density.

3D Mammography had a higher cancer detection

rate and fewer false-positive recalls than standard 2D
imaging
DUCTOGRAPHY
Primary indication: nipple discharge
o Particularly when the fluid contains blood
Radiopaque contrast media is injected into one or
more of the major ducts and mammography is
performed
A duct is gently enlarged with a dilator and then a
small, blunt cannula is inserted under sterile
conditions into the nipple ampulla
With the patient in a supine position, 0.1 to 0.2 mL of
dilute contrastmedia is injected and CC and MLO
mammographic
views
are
obtained
without
compression
Intraductal papillomas are seen as small filling
defects surrounded by contrast media

Cancers may appear as irregular masses or as

multiple intraluminal filling defects
ULTRASONOGRAPHY
An adjunct modality
o Often required in further work up of a
mammographic evaluation
o In younger women (<35 yrs) whose breast tissue
is too dense to assess mammographically
Ability to distinguish solid from cystic lesions
Non-invasiveness
No radiation
o It is useful in pregnant women esp in 1st trimester
Useful as guide
o In needle aspiration biopsy procedures
o In placing a localizing wire to direct an excision
biopsy
Second to mammography in frequency of use for
breast imaging
Important method of
o Resolving equivocal mammographic findings
o Defining cystic masses
o Demonstrating the echogenic qualities of specific
solid abnormalities
Breast cysts are well circumscribed, with smooth
margins and an echo-free center
Findings of benign cyst
o Simple cyst
Meets 4 criteria
1. Round or ovoid
2. Thin smooth walls
3. Absence of internal echoes
4. Posterior acoustic enhancement
o Complex cyst
Does not meet all 4 criteria for simple cyst
o Fibroadenoma
Well-defined borders and internal echoes with
displacement of tissue planes

Transcribers:
Page 2 of 4

UTZ breast CA w/ calcification

Simple cyst
cystic mass

Complex solid and

Complex solid and cystic mass (intracystic papillary

tumor)

UTZ
9
mm
speculated mass w/
attenuation

Used to guide
o fine-needle aspiration biopsy
o core-needle biopsy
o needle localization of breast lesions
Its findings are highly reproducible and it has a high
patient acceptance rate, but it does not reliably
detect lesions that are 1 cm in diameter
Can also be utilized to image the regional lymph
nodes in patients with breast cancer
The features of a lymph node involved with cancer
include
o cortical thickening
o change in shape of the node to more circular
appearance
o size larger than 10 mm
o absence of a fatty hilum and hypoechoic internal
echoes

Benign breast masses usually show smooth contours,

round or oval shapes, weak internal echoes, and welldefined anterior and posterior margins

Normal axillary lymph node

axillary lymph node
Fibroadenoma
papilloma

Intraductal

Breast cancer characteristically has irregular walls

but may have smooth margins with acoustic
enhancement
Findings of malignant lesion:
o Poorly defined borders
o Irregular broad acoustic shadowing with
heterogneous internal echoes
o Disruption of tissue layers

25 mm irregular mass
implant

Indeterminate

UTZ 30 mm mass anterior to

Malignant-appearing axillary lymph node

MAGNETIC RESONANCE IMAGING
imaging modality that combines magnetic and
radio waves to produce detailed images of organs
and structures w/in the body
adjunct to other imaging modalities
o when used with mammography and ultrasound,
can provide better information than when either is
used alone
no radiation
o hence can be used on patients not appropriate to
be exposed to radiation (pregnant women, etc)
useful as screening for younger women not
recommended not to have screening mammography
detects breast cancer in women with breast
implants
detects breast lesions in younger women who tend to
have dense breast tissue
o mammography tends to miss small breast lesions
in younger women who have denser breast tissue
limitations
o not always able to distinguish the difference b/w
cancerous abnormalities
leads to unrecognized or missed cancer lesion
leads to unnecessary biopsies
- when MRI report is not definite, the clinician
may choose to have a biopsy rather than
miss a cancerous lesion
who will benefit from MRI if used as screening?
o Guidelines
from
American
Cancer
Society
recommended screening MRI with mammography
for certain high-risk women such as:
Women with BRCA1 or BRCA2 mutation

Transcribers:
Page 3 of 4

- BRCA1 is a gene which, when altered,

indicates an inherited susceptibility to
cancer
- BRCA2 is a gene which, when altered,
indicates an inherited susceptibility to
breast &/or ovarian cancer
Women with a 20% to 25% or greater lifetime
risk of breast cancer
Women who have had radiation treatment
to the chest between ages 10 & 30, such as
for treatment of Hodgkin disease
Women with the ff genetic disorders or those
who have a first degree relative with the
syndrome
- Li-Fraumeni syndrome
- Cowden syndrome
- Bannayan-Riley-Ruvalcaba syndrome
Additional breast lesions have been detected
However, in the circumstance of negative findings on
both mammography and physical examination, the
probability of a breast cancer being diagnosed by
MRI is extremely low
Women who have a strong family history of breast
cancer or who carry known genetic mutations require
screening at an early age
o Because mammographic evaluation is limited due
to the increased breast density in younger women
MRI study of the contralateral breast in women with a
known breast cancer has shown a contralateral
breast cancer in 5.7% of these women

MRI examination revealing contralateral breast cancer

in a patient diagnosed with unilateral breast cancer on
mammography.
MRI can also detect additional tumors in the index
breast (multifocal or multicentric disease) that
may be issed on routine breast imaging and this may
alter surgical decision making

A BIRADS lexicon is assigned to each examination

and an abnormality noted on MRI that is not seen on
mammography requires a focused ultrasound
examination for further assessment.
If the abnormality is not seen on corresponding
mammogram or ultrasound then MRI guided biopsy is
necessary
Some clinical scenarios where MRI may be useful
include
o the evaluation of a patient who presents with
nodal metastasis from breast cancer without an
identifiable primary tumor
o to assess response to therapy in the setting of
neoadjuvant systemic treatment
o to select patients for partial breast irradiation
techniques
o evaluation of the treated breast for tumor
recurrence
BREAST IMAGING REPORTING AND DATA SYSTEM
(BIRADS)
Standardized system for categorizing the results of
mammograms
Aids the clinician in decision making to standardize
interpretation b/w radiologists, and to be used in
statistical analyses of mammography practice
The BIRADS assessment categories can be
summarized as follows
o Category 0: need additional imaging evaluation
o Category 1: negative
o Category 2: benign finding
o Category 3: probably benign, short interval
follow-up suggested
o Category 4: suspicious abnormality, consider
biopsy
o Category 5: highly suggestive of malignancy
OTHER IMAGING PROCEDURES RELATED TO
BREAST DISEASES
BONE SCAN
o Used to evaluate bone metastasis from breast
cancer
o Less than 1% pick up rate for those asymptomatic
CHEST CT SCANS
o Used as adjuncts in evaluating extent of breast
cancer for staging purposes, tumor involvement of
the chest wall, metastatic lesions
CHEST X-RAYS
o Not frequently used to evaluate chest wall
involvement
o Frequently used to asses pulmonary metastasis,
as first line imaging

MRI imaging of the breast revealing multifocal tumors

not detected with standard breast imaging.
MRI has been advocated by some for routine use in
surgical treatment planning
o Additional disease can be identified with this
advanced imaging modality and the extent of
disease may be more accurately assessed
The use of MRI was associated with increased
mastectomy rates
o This is problematic since there is no evidence that
the additional disease detected by MRI is of
clinical or biologic significance
Particularly in light of the low local-regional
failure rates currently reported in patients
undergoing breast conserving surgery who
receive whole breast irradiation and systemic
therapies
The use of dedicated breast coils is mandatory in
the MRI imaging of the breast

Transcribers:
Page 4 of 4