Breast Imaging

Female breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts, made of glandular, adipose, and connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue, are hormone-sensitive organs that undergo changes along with the menstrual cycle Menstrual cycle The menstrual cycle is the cyclic pattern of hormonal and tissular activity that prepares a suitable uterine environment for the fertilization and implantation of an ovum. The menstrual cycle involves both an endometrial and ovarian cycle that are dependent on one another for proper functioning. There are 2 phases of the ovarian cycle and 3 phases of the endometrial cycle. Menstrual Cycle and during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care. Breasts may be affected by various diseases, in which different imaging methods are important to arrive at the correct diagnosis and management. Mammography is used for breast cancer screening Breast cancer screening Breast cancer is the most common cancer in women and the 2nd-leading cause of cancer-related deaths in women in the United States. Early detection and improved pathology-specific treatments have resulted in a decrease in death rates. Breast Cancer Screening and diagnostic evaluation of various breast-related symptoms. Ultrasonography is rarely used for screening, but it is typically used for diagnostic workup and during procedures (e.g., breast biopsy). MRI of the breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts is used as a supplementary screening tool for those at high risk for developing breast cancer. Additionally, in individuals with breast implants, inconclusive mammographic and/or breast ultrasound findings, and diagnosed breast cancer needing evaluation pretreatment and posttreatment, MRI is an important breast radiologic tool.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Mammography

Mammogram

  • Film-screen mammogram: uses X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays, radiographic film and intensifying screens to produce an image of the breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts
  • Digital mammogram: a digital detector takes the place of the film and screen

Indications

  • Screening:
    • All women ≥ 40 years of age are recommended to undergo mammography for early detection of breast cancer or precancerous lesions.
    • Frequency recommendations vary with medical organizations.
    • High-risk individuals (e.g., calculated lifetime risk of breast cancer > 20%) by age 30, are recommended to have:
      • An annual mammogram, AND 
      • Breast MRI (typically alternating every 6 months between the 2) 
  • Diagnostic mammogram:
    • Evaluation of palpable mass in women > 30 years of age 
    • Abnormality found on routine screening mammogram
    • Evaluation of women presenting with breast pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or tenderness, nipple discharge, skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin and nipple changes

Contraindications

There are no absolute contraindications, but there are relative ones (owing to adverse effects of radiation exposure).

  • Pregnancy (mammography can be postponed if individual is asymptomatic and has average risk for breast cancer)
  • Lactation:
    • Lobules attenuate X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays, thus increasing the density of the breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts
    • Visualization of lesions will be difficult.
  • Women < 30 years of age: increased sensitivity to radiation

Mammogram views

Table: Mammogram views
Views Description
Standard views Mediolateral oblique (MLO) view Better view of the superior lateral quadrant of the breast and axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus
Craniocaudal view (CC)
  • Medial part of the breast: lower part of image
  • Lateral part of the breast: upper part of image
Specialized views Spot compression Better visualization of suspicious masses, calcifications, or asymmetric breast tissue
Magnification
XCCL (exaggerated CC lateral) view Modified CC view, focused on the lateral part of breast
XCCM (exaggerated CC medial) view Modified CC view, focused on the medial part of the breast

Normal findings

  • Normal breast is composed of:
    • Parenchyma (ducts and lobules)
    • Connective tissue
    • Fat
  • Breast findings:
    • Brighter signal represents fibroglandular tissue.
    • Gray areas represent adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or "brite" adipose tissue, which is a transitional form. Adipose Tissue.
  • Breast density: 
    • Findings can be: 
      • Extremely dense (which can obscure lesions or cancers)
      • Heterogeneously dense 
      • Scattered fibroglandular 
      • Almost entirely fatty
    • Young women typically have denser breast tissue.
    • Older women have a higher amount of fatty tissue.

Mammographic assessment categories

Table: Mammographic assessment categories
Category Assessment Follow-up
BI-RADS 0 Incomplete assessment Additional mammography views or ultrasound follow-up needed
BI-RADS 1 Negative Continue with routine screening
BI-RADS 2 Benign findings Continue with routine screening
BI-RADS 3 Probably benign findings Diagnostic mammography or ultrasound in 6 months
BI-RADS 4 Suspicious abnormality Biopsy should be considered.
BI-RADS 5 Highly suggestive of malignancy Biopsy should be performed.
BI-RADS 6 Biopsy-proven malignancy Management for breast cancer
BI-RADS: Breast Imaging Reporting and Data System

Breast Ultrasound

Indications

  • Evaluation of any palpable finding (ideal initial study for women who are < 30 years of age, pregnant, or lactating)
  • Further evaluation of abnormal masses found during mammography or MRI scans
  • Method for guidance for biopsy of breast tissue
  • Assessment of the axillary, supraclavicular, and infraclavicular lymph nodes in cases of suspicion of breast cancer
  • Can infrequently be used as an adjunct to screening in women with dense breast tissue 

Normal findings

  • Young nonlactating breast: 
    • Mainly composed of echogenic fibroglandular tissue, with little to no fat 
    • Greater amounts of adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or "brite" adipose tissue, which is a transitional form. Adipose Tissue are deposited with increasing age/parity.
  • Lactating breast: prominent fluid-filled ducts with echogenic epithelial lining

Breast MRI

MRI of the breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts

Radiologic technique that uses magnetic fields and radiofrequency pulses to produce highly detailed images of the breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts.

Indications

  • Screening:
    • Indicated as supplementary screening along with mammography in women with a high risk of breast cancer
      • BRCA1 or BRCA2 mutations
      • Strong family history of breast and/or ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer
      • History of mantle-cell radiation for Hodgkin lymphoma Hodgkin lymphoma Hodgkin lymphoma (HL) is a malignancy of B lymphocytes originating in the lymph nodes. The pathognomonic histologic finding of HL is a Hodgkin/Reed-Sternberg (HRS) cell (giant multinucleated B cells with eosinophilic inclusions). The disease presents most commonly with lymphadenopathy, night sweats, weight loss, fever, splenomegaly and hepatomegaly. Hodgkin Lymphoma
    • Used as follow-up for an abnormal or inconclusive mammography result
  • Detection of occult breast cancer in an individual presenting with axillary lymph nodes diagnosed with metastatic disease
  • In diagnosed breast cancer, MRI aids in preoperative evaluation and staging Staging Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis, as well as in measurement of response to chemotherapy.
  • Evaluation of breast implants
  • Evaluation of inconclusive mammograms or ultrasounds
  • In cases of dense breast tissue, which hinders other tests

Contraindications

A breast MRI is contraindicated in MRI-incompatible hardware or anaphylaxis to gadolinium.

MRI findings

Findings are grouped into 3 categories:

  • Focus/foci: area of enhancement measuring < 5 mm in diameter 
  • Mass:
    • A lesion that occupies a space within the breast
    • The shape, margins, and enhancement pattern of the mass are of special diagnostic value.
    • Benign lesions often show progressive enhancement.
    • Among the findings seen in malignancy:
      • Masses with irregular or spiculated margins
      • Rapid uptake and washout of gadolinium
  • Non–mass-like enhancement: 
    • Areas of enhancement without a detectable 3-dimensional mass
    • Distribution can be diffuse, regional, segmental, or linear.
    • Enhancement can vary: heterogeneous, homogeneous, clumped, or clustered

Abnormal Findings

Breast cysts

  • Ultrasonography findings:
    • Simple cyst:
      • Well-defined round/oval lesion 
      • No internal echo (anechoic)
      • Thin, regular walls
      • Posterior acoustic enhancement
    • Complex cyst:
      • Presence of internal echoes caused by accumulation of pus, blood, or milk
      • Absence of posterior wall enhancement
      • Chronic cysts may be ill defined.
  • Mammography findings:
    • Oval or spherical shape
    • Smooth, well-defined borders

Fibrocystic changes

  • Ultrasonography findings (highly variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables):
    • Focal areas of thickening (patchy increase in echogenicity)
    • Single cysts or clusters of small cysts
  • Mammography findings:
    • Heterogeneous and usually dense parenchyma 
    • Partially circumscribed masses 
    • Tea-cup, low-density round calcifications 

Fibroadenoma Fibroadenoma Fibroadenomas are the most common benign tumor of the female breast and the most common breast tumor in adolescent and young women. The tumors are well-circumscribed, mobile, and unencapsulated, with a rubbery or firm consistency. Fibroadenoma

  • Ultrasonography findings:
    • Well-defined spherical lesion
    • Smooth borders (capsule)
    • Uniform hypoechogenicity
    • May or may not present with internal echoes
    • Transverse diameter > anteroposterior diameter (insinuating that it does not invade through fascial planes)
  • Mammography findings:
    • Well-circumscribed oval or spherical mass
    • Smooth, regular borders
    • Hypodense or isodense to glandular tissue
    • May present with lobulations
    • Popcorn-shaped calcifications (in involuting fibroadenomas)

Lipoma Lipoma A lipoma is a benign neoplasm of fat cells (adipocytes) and the most common soft tissue tumor in adults. The etiology is unknown, but obesity is a predisposing factor; genetics also play a role, with multiple lipomas occurring in various inherited disorders. Lipoma

  • Ultrasonography findings:
    • Well-defined echogenic lesion
    • Soft consistency; can be deformed by compression with the transducer
    • Lamellar appearance and thin capsule
  • Mammography findings:
    • Radiolucent mass with no calcification
    • May have a thin, peripheral, fluid density capsule
Ultrasound image of a well-defined subtly-echogenic mass

Ultrasound image of a well-defined subtly echogenic mass (lipoma) with a lamellar pattern and a well-defined, thin capsule (arrows)

Image: “ Lipoma Lipoma A lipoma is a benign neoplasm of fat cells (adipocytes) and the most common soft tissue tumor in adults. The etiology is unknown, but obesity is a predisposing factor; genetics also play a role, with multiple lipomas occurring in various inherited disorders. Lipoma” by Gokhale, S. License: CC BY 2.0

Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer

  • Ultrasonographic characteristics of malignant lesions:
    • Usually hypoechoic 
    • Ill-defined or irregular borders
    • Anteroposterior diameter > transverse diameter (insinuating that it does invade through fascial planes)
    • Spiculated margins
    • Posterior acoustic shadowing
    • Microcalcifications
    • Significant vascularity seen on Doppler imaging
  • Mammography: 
    • Characteristics of benign breast masses:
      • Well-defined, circumscribed mass
      • Radiolucent ring surrounding the lesion (halo sign)
      • Diffuse microcalcifications
      • Presence of fat in a mass
    • Characteristics of malignant lesions:
      • Hyperdense masses 
      • Fine linear branching microcalcifications
      • Irregular borders
      • Spiculation
      • Architectural distortions
  • MRI findings:
    • Irregular borders
    • Spiculations
    • Segmental distribution and calcifications
    • Enhancing internal septations
    • Perilesional edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema: clustered ring enhancement
    • Heterogeneously enhancing pattern

Fat necrosis

  • Ultrasonograpy findings:
    • Hypoechoic mass with well-defined margins
    • May or may not have mural nodule(s)
    • Can produce significant shadowing secondary to coarse calcifications
  • Mammography findings:
    • May present as an ill-defined, irregular, spiculated mass (similar to breast cancer)
    • Oil cysts
    • May appear with egg-shell calcifications

Breast hamartoma

  • Benign slow-growing breast lesion (uncommon)
  • Contains fat and fibrous tissue and presents as painless masses
  • Ultrasonography findings:
    • Margins are difficult to detect because it resembles normal breast tissue.
    • May present with internal echoes that are a mix of hyperechoic and hypoechoic components 
  • Mammography findings:
    • Well-circumscribed spherical or oval compressible mass with thin capsules
    • Heterogeneous: contains both fat and soft-tissue internal densities
Mammogram showing a fat-containing oval mass, suggestive of hamartoma

Mammogram showing a fat-containing oval mass, suggestive of hamartoma

Image: “A 26-year-old pregnant female with a new palpable mass” by Ojeda-Fournier H, Nguyen JQ. License: CC BY 2.0

References

  1. Aydin, H. (2019). The MRI characteristics of non-mass enhancement lesions of the breast: associations with malignancy. Br J Radiol 92:20180464. https://doi.org/10.1259/bjr.20180464
  2. Farrokh, D., Hashemi, J., Ansaripour, E. (2011). Breast hamartoma: mammographic findings. Iran J Radiol 8:258–260. https://doi.org/10.5812/iranjradiol.4492
  3. Freimanis, R.I., Ayoub, J.S. (2011). Radiology of the breast. Chapter 5 of Chen, M.M., Pope, T.L., Ott, D.J. (Eds.), Basic Radiology, 2nd ed. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=360&sectionid=39669012
  4. Reeves, R.A., Kaufman, T. (2021). Mammography. StatPearls. Retrieved November 23, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK559310/
  5. Slanetz, P. (2021). MRI of the breasts and emerging technologies. UpToDate. Retrieved December 11, 2021, from https://www.uptodate.com/contents/mri-of-the-breast-and-emerging-technologies
  6. Tozaki, M., Igarashi, T., Fukuda, K. (2006). Breast MRI using the VIBE sequence: clustered ring enhancement in the differential diagnosis of lesions showing non-masslike enhancement. AJR Am J Roentgenol 187:313–321. https://pubmed.ncbi.nlm.nih.gov/16861532/

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