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Series E Number 27

MAMMOGRAPHIC ATLAS
MAMMOGRAPHIC ATLAS Reading System of Valencia Breast Cancer Screening Programme in Valencia Community

Reading System of Valencia Breast Cancer Screening Programme in Valencia Community

Prevention of Breast Cancer

HEALTHCARE MONOGRAPH SERIES E NUMBER 27


C O N S E L L E R I A D E S A N I TAT

MAMMOGRAPHIC ATLAS Reading System of Valencia Breast Cancer Screening Programme

Published by: Generalitat Valenciana Autonomous Government Health Authority For further information please get in touch with: Direccin General de Salud Pblica Unidad de Prevencin de Cncer C/ Micer Masc, 31 46010 VALENCIA, SPAIN Telephone n: (+34) 96 386 66 01 E-mail: pcancer_val@gva.es

Project 172/2000 To structure a computerized screening mammography file for training and evaluation of the readers 2nd edition financed by the European Commission, 2000

Copyright: 2001 Direccin General para la Salud Pblica. Conselleria de Sanidad. Translation: Borgon. Traducciones y Textos.

National Book Catalogue Number: V - 32 - 2002


Printed by: Grficas Mar Montaana, s.l. Santo Cliz, 7 46001 VALENCIA (Spain) Tel. 96 391 23 04* Fax 96 392 06 39
E-mail: imprenta@marimontanyana.com

MAMMOGRAPHIC ATLAS Reading System of Valencia Breast Cancer Screening Programme (VBCSP) SPAIN

EDITORS FRANCISCO RUIZ-PERALES Chief of Mammography, Departament of Radiology University Hospital La Fe Radiology Coordinator of the VBCSP

ISIDRO VIZCANO ESTEVE Chief of Mammography, Departament of Radiology University Hospital Dr. Peset Radiology Consultant of the VBCSP

PRESENTATION

or some years now mammographic screening has been used in the Valencia Community for the early detection of breast cancer. This is currently being made available to all women from 45 to 65 years of age (in the next two years this age group will be extended to 69), at twenty-three Breast Cancer Screening Facilities working to the recommendations of the European Communitys Europe Against Cancer (EAP) programme. This attempt to provide prevention for a wide range of the population requires new efforts day in, day out, in order to ensure that all the professionals involved have the very best qualifications and commitment. Mammographic studies form the central mainstay of breast cancer screening programmes, whose final results are to be a reduction in mortality. Mammography can only fulfil its role as a test for screening if a technical level and an excellent reading quality are ensured to allow the diagnosis of breast cancer in its early stages, thus implementing secondary prevention of this disease. To obtain the highest standard of uniformity in reading a reading system was implemented and then gradually updated and established by consensus, through the teamwork of a group of readers from the Programme. The result of this process was the publication of the Mammographic Atlas (Valencia Breast Cancer Screening Programme Reading System) which was published in 1998. The updated edition of the Mammographic Atlas in English forms part of a project by the European Breast Cancer Network, which was joined by the Valencia Community in 2000. This network is characterised by cooperation between European Union countries and a synergetic approach to its work. The project aims to build a computerised mammographic library to enable the training and official recognition of mammography readers in screening programs. A CD-Rom has also been made with images of biopsied cases to support continuing training. Training of professionals and physical-technical quality forms part of an approach to population screening as a process in which only quality assurance in each and all of its aspects can ensure that people are provided with a preventive option in line with the most demanding international standards.

The Autonomous Government Health Authority Serafn Castellano Gmez

INDEX OF AUTHORS Andreo Hernandez Luis A. Hospital Virgen de los Lirios. Alcoi. Coll de la Vega, Margarita. Unidad de prevencin de cncer de Mama. Xativa. Gadea Boronat, Leopoldo. Unidad de prevencin de cncer de mama. Alcoi. Garca Redn, Teresa. Unidad de prevencin de cncer de mama. Castelln I. Hernandez Jimenez, Angel. Unidad de prevencin de cncer de mama. Alicante I. Martn Diez, Flix. Hospital Lluis Alcanyis. Xtiva. Montes Avila, Manuel. Hospital General de Elda. Olage de Ros, Ramn. Hospital General de Requena. Redondo Ibaez, Marta. Hospital General de Castelln.

CONTRIBUTORS Abderraman, Isa Musa; Aguilar Gmez, Nieves; Agull Baeza, Trinidad; Alberola Quintar, Mara Luisa; Ardoy Ibez, Francisco; Carnero Ruiz, Mara; Casals El Busto, Mara; Cervera De Val, Jos; Chorda Grau, Dulce Concepcin; Moscard, Luis; Cubells Martnez, Mara Luisa; Erades Martnez, Daniel; Estells Lerga, Pilar; Fernndez lvarez, Gloria; Fernndez Garca, Pilar; Ferrando Valls, Federico; Ferriols Ballester, Amparo; Florencio Quilis, Ignacio; Fuster Selva, M. Jos; Galant Herrero, Joaqun; Gallego Gato, Juan; Garca Franco, Margarita; Gil Cruz, Pedro Manuel; Gmez Lorente, Carlos; Jordn Balanz, Yolanda; Laso Pablos, Mara Soledad; Martnez Gmez, Inmaculada; Martnez Prez, M. Jess Masip Sanchis, Mara Jos; Morcillo Tur, Enma Yolanda; Morote Muro, Virgilio Nez De Bobadilla, Jos; Olmos Martnez, M. Teresa; Ortega Gutierrez, Concepcin; Ort Tarazona, Carlos; Palmi Cabedo, Pascual; Palop Jonqueres, Carmen; Prez Clavijo, Jos Mara; Perona Zuriaga, Isabel Piqueras Olmeda, Rosa; Sanchis Aparicio, Manuel; Vidal Ferrer, Pascual; Vidal Lluch, Juan Sebastian ; Zaragoza Cardells, Eduardo.

VBCSP COORDINATING COMMITTEE PRESIDENT: Manuel Escolano Puig. General Director of Public Health. Autonomous Government Health Authority. MEMBERS: Dolores Salas Trejo. Head of the Cancer Prevention Programme. M Dolores Cuevas Cuerda. Central Administration Health. Monserrat Snchez Lorente. Central Administration Health. Francisco Ruiz Perales. Radiology. Isidro Vizcano Esteve. Radiology. Ignacio Aranda Lpez. Pathology. Vicente Torres Gil. Pathology. Ignacio Petschen Verdaguer. Radiotherapeutic oncology. Ana Lluch Hernndez. Medical oncology. Constantino Herranz Fernndez. Medical oncology. Carlos Vazquez Albadalejo. Surgery. Ignacio Villaescusa Blanca. Radiological protection.

ACKNOWLEDGEMENT We would like to express our special thanks to photographers Salvador Peir, Ricardo Acosta and Francisco Ara for their generous contribution in making all the figures included in this atlas.

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CONTENTS

Pages
13 17 23 29 33 39 43 49 57

CHAPTER I. THE MAMMOGRAPHIC REPORT ................................................ CHAPTER II. CATEGORY 1. NORMAL ........................................................ CHAPTER III. CATEGORY 2. BENIGN ......................................................... CHAPTER IV. CATEGORY 3. PROBABLY BENIGN ....................................... CHAPTER V. CATEGORY 4. PROBABLY MALIGNANT.................................. CHAPTER VI. CATEGORY 5. MALIGNANT .................................................. CHAPTER VII. MISCELLANEOUS ................................................................... APPENDIX I. DIAGNOSTIC PROTOCOL. ........................................................ APPENDIX II. WORK SHEET ......................................................................... FIGURES: NORMAL ................................................................................................ BENIGN ................................................................................................. PROBABLY BENIGN ............................................................................... PROBABLY MALIGNANT ......................................................................... MALIGNANT ........................................................................................... MISCELLANEOUS ................................................................................... INDEX OF FIGURES ...................................................................................... INDEX OF TERMS USED ...............................................................................

61 75 93 109 131 141 155 159

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CHAPTER I THE MAMMOGRAPHIC REPORT


F. Ruiz Perales

The mammographic report in a screening programme is not the same as the one used in a mammary pathology diagnosis facility. At mammary pathology facilities, reports tend to be presented in form of free text, sometimes using histopathological terms, when the correlation between the radiological image and pathology is simply a subjective impression and sometimes referring to the result of applying several techniques, frequently mammography with ultrasound, to obtain a joint report (1-3). In a screening programme, the aim of the mammography report is to separate cancer-free people from those with some possibility of having cancer, and at the same time to classify the second group by their greater or lesser probability of having breast cancer. The classifications may vary, but their aim is to make decisions allowing the final diagnosis of cancer or no cancer to be established. The approaches involved will naturally be more aggressive the greater the probability of suffering from cancer and more conservative the lower this probability (1). We should be aware of the fact that there are exceptionally cancers that are not visible in the mammography, even though the breasts are fatty, because these are invisible and more often because they are hidden deep in breasts with dense tissue, which occasionally make it difficult or impossible to identify them by radiology. There are cancers which are palpable before they can be identified by their radiological signs (1, 4, 5). Occult cancer is a real fact but does not give any authorisation to predict the existence of cancer without there being any radiological or clinical signs and neither should it lead to ambiguous reports which safeguard the person who issues them but do not assist the patient nor any of the specialists involved in the diagnosis and treatment of breast cancer. The mammography report in a screening system should be based on a data collection system that is as objective as possible, that does not allow varied interpretations, confused descriptions and, even less, misleading or ambivalent attitudes. It should be simple, using a pre-established lexis, in which each of the terms to be used has been defined, in order to do this properly, allow the collection of data in the simplest way, devoting the minimum time to writing, with a view to leaving the maximum time for reading the radiographic films. An attempt should be made to use a data collection system that can be easily transcribed on a computer support (1, 6, 7). Most screening programmes have adopted and registered a reading system, developing this according to the needs that they have come up against and the resources available. When the aim is to standardise reports of different programmes, the reading protocols should be painstakingly developed, applied to practice in previous tests and continuously reviewed by the readers who use them.
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Although all reading systems have a common aim and the cancer detection rate of screening programmes is what best vouches for their efficiency, they differ in the data collection methodology and sometimes in the terms used, it proving very difficult to match readings in all screening programmes. Some reading systems have been developed to solve a particular situation, while others propose the adoption of a universal system, and if this objective were attained, it would undoubtedly mean benefits for all and not only through allowing a large amount of case data to be compiled but also because it would act as a reading quality control and would act as the basis for teaching interpretation of mammographies. (1, 4-7). The purpose of this Mammographic Atlas is to divulge the reading system used at the Valencia Breast Cancer Screening Programme (VBCSP) in the Valencia Community, illustrating this with images which can be used as an example for all the physicians interested in screening programmes and above all those who are interested in film reading, for radiologists and also for the specialists involved in these multidisciplinary programmes in which the terms used by each speciality should necessarily be known. The reading system is based on the suggestions published in the works by Svane and co. (8 ) in 1992 and Koppans (9) in 1993, and developed at work meetings of the group of readers in the programme. It is published in the form of a modus operandi in Sanitary Monographs, Series E number 14.(4) and Series E, number 19 (5), Series E, number 25 (1) and Series E, number 27 (13). All the terms constituting the lexis of the report system have been properly defined, not only in their medical meaning but also as regards their meaning in the Royal Spanish Academy Language Dictionary. We thus hope that no interpretations other than the ones described are possible (10, 11). After accepting and defining normality, we have attempted to include in the benign and malignant categories the pathology in which there is an almost absolute correspondence between the reading and the pathology. In these cases the use of pathology terms can be accepted. (Example: Lipoma) (13). Women with some likelihood of having breast cancers have been classified in the probably benign and probably malignant categories, depending on whether there is a lesser o greater possibility of suffering from this. In these reports, as correlations between the radiological image and the pathological anatomy are not absolute, only the terms describing the mammographic image should be used. (For example: Nodule 13). The choice of these categories has the aim of adopting different approaches for each of these. In the normal category, women are checked again two years later, this being the interval time of our programme. The benign category, from the standpoint of the screening programme, will be reviewed after two years, and nevertheless the pathology included in this category may require some type of treatment by the physician or specialist (Example: Painful cyst 13). Probably benign and probably malignant categories are the main objective of screening programmes. For patients falling into these categories there should be complementary studies, additional projections, ultrasound, short-term follow-up, in order to establish follow-up, cytological or histological studies, with a view to reaching a definitive diagnosis. An attempt is made to implement approaches proportional to the probability of suffering from cancer, with conservative procedures in the probably benign cases and interventionist approaches in the probably malignant ones (1, 2, 4, 5, 13). The cancers diagnosed by the clinic and radiology and which are occasionally found in screening programmes for different causes which are not analysed here should be sent on to hospital breast facilities, to proceed to their treatment. It would be desirable for all women participating in cancer screening programmes to be asymptomatic. The present reading system has been regularly modified according to the results obtained in the programme and this leads to suppose that they will continue to be modified, partly for the same reason and partly because technology is constantly moving on and these known motives and possibly some that we do not know of now will lead the system to change to adapt continuously to the new requirements (13). The reading system has proved very useful over the years in which this has been used up to the present time, but many programmes nevertheless follow the guidelines proposed by A.C.R in the BIRADS system. The universality of the BIRADS system is the present requirement. (14, 15)
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This fact forces us to review and compare both systems and we conclude that they are compatible, with minimum differences which are not vital nor affect the final classification in Categories, which are the same for both systems and consequently so is the approach to be followed after the classification. The divergences existing, in some cases nuances rather than differences, are given in Appendix I and refer to the classification of the reading data (13-15). When reviewing the Mammographic Atlas. Reading System of the VBCSP in the Valencia Community for a new edition, we wish to state that this was agreed by consensus at the Encounter Sessions held in Valencia on November in 1997. In the update we give the corrections which have been jointly made since its publication. (13). The reading system includes modifications or simply qualifications for better understanding as the observations of those using it are analysed or as new requirements come up. The development of Appendix I, which we are using at present as reading system, will explain the compatibility with the BIRADS system. We would finally like to express our thanks to all those who contributed to creating the reading system for the VBCSP in the Valencia Community. A list of the present readers and the ones that at some time have worked on the programme and contributed to forming this procedure is given at the beginning of the present reading text found below.

Bibliography
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Generalidad Valenciana. Conselleria de Sanitat.Programa de prevencin de cncer de mama en la Comunidad Valenciana. Monografia Sanitaria. Serie E, Nm. 25. Valencia: Generalitat Valenciana, 1998. Farmapress. Grupo Aula Mdica, S.A. Screening de mama. Abstracts del I Curso Internacional de la Sociedad Espaola de Diagnstico por Imagen de la Mama (SEDIM). Madrid 1998. Hommer MJ. Mammography Report (editorials). AJR 1984: 142; 643-644. Generalidad Valenciana. Conselleria de Sanitat. Programa de prevencin del cncer de mama en la Comunidad Valenciana. Monografa Sanitaria. Serie E. Nm. 14; Valencia: Generalitat Valenciana, 1993. Generalidad Valenciana. Conselleria de Sanitat. Programa de prevencin del cncer de mama en la Comunidad Valenciana. Monografia Sanitaria. Serie E. Nm.19; Valencia: Generalitat Valenciana, 1996. Homer MJ. Mammographic Interpretation. A Practical Approach. New York: Mc. Graw-Hill, 1997: 2733. American College of Radiology (ACR). Breast Imaging Reporting and Data System (BI-RADS). (2nd edi.) Reston (VA): ACR, 1995. Bassett LW. Standardized Reporting for Mammography: (BI-RADS). The Breast Journal 1997; 3: 207210 Svane G, Potchen EJ, Sierra A, Azavedo E. Stellate lesions. In: Patterson A. ed. Screening Mammography. Breast Cancer Diagnosis in Asymptomatic Women. St. Louis: Mosby Year Book, 1993. Kopans DB. Standardized Mammography Reporting. Radiol. Clinics of North Amer. 1992; 30:257-264. Real Academia de la Lengua. Diccionario de la Lengua Espaola. Madrid: Espasa-Calpe. 2001. Diccionario de Sinnimos y Antnimos. Madrid: Espasa-Calpe. 1994. Generalidad Valenciana. Conselleria de Sanitat. Atlas Mamogrfico. Sistema de Lectura del Programa de Prevencin de Cncer de Mama en la Comunidad Valenciana. Monografa Sanitaria. Serie E, Nmero 27. Valencia: Generalitat Valenciana. 1998. American College of Radiology (ACR). Breast Imaging reporting and data system (BI-RADS). (Third Edition). Reston [VA]: American College of Radiology; 1998. Kopans DB. Tratamiento de datos, falsos negativos y revisin del estudio de la mama. In: la mama en imagen. Madrid: Marban. 1999: 761-796.

14. 15.

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CHAPTER II CATEGORY 1. NORMAL


Dr. R. Olage
Introduction If normal is the term applied to what acts as a norm or rule, the fact of the breast being a dynamic organ subject to a wide range of histological/mammographic changes is the reason for the difficulty in defining this as such. Changes of a proliferative nature take place in pre-menstruation, pregnancy, lactation, and during hormone replacement therapy (HRT), particularly when estrogens with progesterone are administered continuously (1-3). Involutional physiological alterations are also observed from 30 years of age and in treatment with Tamoxifen (4). The problem is further complicated if we take into account the variability of the mammary glands individual response to the aforementioned changes. As Homer points out, the breast is like a fingerprint, every single one is different (5). Nevertheless, to be pragmatic in establishing the modus operandi, we will use the term normal for the breast that does not display signs of a pathological nature in mammography, considering these signs to be ones that form the description or mammographic reading (nodule/mass, structural alteration, calcifications, asymmetries and alterations of the skin or nipple), in the sense in which these are respectively defined within the categories of benign, probably benign, probably malignant and malignant, and which will be dealt with in the following chapters (6). Although the classic patterns of mammographic reading can be reduced to three types (fatty, dense and mixed) in relation to the greater or lesser presence of fibroglandular tissue, in our reading protocol we have only established two subcategories within the normal category: 1.1 NORMAL FATTY: This refers to a breast with a large fatty component, or scanty glandular tissue, mammographically radiolucent, in such a way as to make it difficult to cover up nodules, alterations of densities or neodensities (Fig 1, page 63). 1.2 NORMAL DENSE: Includes any normal breast with visible parenchyma, of homogeneous, macro or micronodular, patchy type, etc. and which can conceal nodules or alterations in density (Fig.2 a and b, pages 63 and 64). The terms used, fatty and dense, refer to the radiological density of the fat and the water, with the same meaning as they are given in conventional radiology. It is true that sometimes, above all in mixed patterns, with no clear predominance of the glandular or fatty component, the establishment of a subcategory is grounds for disagreement between readers. Nevertheless, on condition that the pattern assigned does not conceal nodules or alterations in density, the discrepancy is not of great importance through not implying different action. The introduction of subcategories within the normal breast is justified by their evident practical implications, since the dense breast reduces the sensitivity of the reading in the detection of breast cancer; a radiologically dense breast is more difficult to interpret, because the density can occasionally
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hide the presence of a structural disorganisation, an increase in density in respect of the surrounding stroma, or make the detection of microcalcifications difficult (7). A more thorough mammographic reading, along with a clinical examination and a mammary ultrasound, will contribute to the establishment of the corresponding category and the action stemming from this (8). We should not forget that around 9% of operable cancers have negative mammographic reports, and one of the causes of error is the false interpretation of the cancer as a benign lesion and the difficulty of diagnosing this in dense breasts (9). NODULES IN THE NORMAL CATEGORY 01. Axillary or intramammary lymph nodes whose morphology and size lead them to be considered as normal. Most of the lymphatic drainage of the breast is done by the axillary nodes and the rest by the internal thoracic lymph node chain. In mammography it is common to discover one or more nodules in the axillary tail or medium axillary line, in a topographical relationship with the pectoral muscles and which correspond to axillary lymph nodes. These are to be considered part of the normal anatomy if they meet the following mammographic characteristics: - Nodule of mixed density, moderate or low density and radiolucent centre, with well-defined contours, round, oval or kidney-shaped, and on occasions with hilar groove (Fig. 3, page 64). - Its greatest diameter must not be over 1.5 cm, except when there is fatty infiltration, which could exceed this size (Fig. 4, page 65). When there are occasionally doubts, spot projection with magnification is useful for better identification of the aforementioned characteristics, in particular of the radiolucent fatty hilum (10 ) (Fig. 5, page 65). The 5.4% of mammographies have intramammary lymphatic nodules. These can be isolated, multiple, unilateral or bilateral and their customary seat is the upper-outer quadrant (UOQ), and the periphery of the glandular cone (11). The problem arises when these occasionally settle in other quadrants. If they are not over 1 cm, in diameter, and keep the mammographic characteristics mentioned for axillary lymph nodes, they will come under the normal category. If, on the other hand, these are nodules of under 0.5 cm, that are homogeneous, of low density and with well-defined contours, they will form part of the benign category, and if these are over 0.5 cm and have the same characteristics as the previous one, they will be probably benign and require the corresponding follow-up. In the different evolutionary checks slight changes in size of the lymph nodes can be seen, which are not significant if they keep the fatty hilum, are not palpated and if there is no history of malignancy (12). The mammographic characteristics are in most cases sufficient to establish the diagnosis of the axillary and intramammary lymph nodes, and in a very few exceptions we resort to ultrasound as a complementary test, though these are difficult to identify in fatty breasts. The echographic characteristics are: hypoechoic oval nodules of under 1.5 cm maximum diameter with an echogenic central hilum (13). Spherical and high density lymph nodes with increasing size must be considered as being pathological (Fig. 6, page 66). Given the non-specificity of these findings, which can correspond both to benign pathology (dermopathic lymphadenitis, collagenopathies), or malignant ones (leukaemia/lymphoma, metastasis) (Fig. 7, page 66), they should be valued within the overall context of the mammographic reading and analysis of their specific characteristics, going to form part of the probably benign or probably malignant category, as we will later see in the corresponding section; these should always be given a biopsy, if we do not manage to clearly establish their benign nature. Badly defined margins and infrequent microcalcifications in their interior are of course signs leading one to suspect metastatic carcinoma. 01. Warts or lesions in the skin identified, if possible with a metal mark After mammary inspection of the patient, it is important for the Radiology Technician (RT) to
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inform the radiologist of any lesion protruding from the skin such as warts, naevi, and neurofibromas, which can be projected in the mammographies as intramammary processes. These are seen in the form of well-defined masses of medium or low density, in at least one projection. When these are compressed, the air is trapped around them, giving rise to a characteristic radiolucent halo which surrounds them (Fig. 8, page 67). If the surface is irregular, as occurs in the melanocytic naevus, the air trapped in its surface can be seen in the mammography as mixed density looking like paving. By the same mechanism, as will be seen in the chapter on miscellaneous items, any hygiene powders or dermal creams deposited inside can simulate suspicious microcalcifications. In this case, and in general in all the protruding dermal lesions, if these have not been routinely marked before carrying out the mammographic projection, they can be identified with metal or barium markers, then making a tangential projection (Fig. 9, page 67). Epidermal inclusion cysts or sebaceous cysts, clinically indistinguishable, can cause a discreet swelling in the skin and tend to be located in the areolar zone or lower portions of the breast. These are well circumscribed nodules, with a subcutaneous seat, of medium or high density, which can change in size and occasionally calcify (Fig. 10 a and b, page 68). When they inflame they can have badly defined edges and be accompanied by skin oedema.

STRUCTURAL ALTERATION IN THE NORMAL CATEGORY: 02. Stars produced by the superimposing of structures Pseudostars or constructed images are produced by the superimposing of normal fibroglandular structures when the mammary gland is projected on a single plane. These are only appreciated in a single mammographic projection, but one must take great care since some small-sized cancers can behave in the same way. In the event of any doubt the mammographic projection can be repeated, changing the angle of incidence of the beam of radiation slightly, or making a focalised projection with compression (Fig. 11a and b, page 69) (14, 15).

CALCIFICATIONS IN THE NORMAL CATEGORY: 03. Vascular calcifications Vascular mammary calcifications are a frequent finding in screening mammographies and are correlated with ageing, meaning that these are often observed in postmenopausal women. They settle in the medium level of the peripheral arterioles (Mnkeberg medial calcific sclerosis), with a typical mammographic appearance in rail or double parallel line form, and do not usually involve any diagnosis problem (16, 17) (Fig. 12, page 70). Only in the early phases of the calcification process, when the linear calcifications affect only a part of the wall of the vessel, can they be confused with malignant type linear calcifications. Focal projection with magnification will help to establish their vascular nature (Fig. 13, page 70). 03. Dermic calcifications Calcification of the sebaceous glands is in relation to a chronic folliculitis. Although these are seated in the dermis, being located in a flaccid easily compressed organ means that in the basic mammographic projections they seem to be intraparenchymatous (18). A careful reading of these in a magnified projection will nevertheless reveal the following typical characteristics: They can be seen in isolated or multiple groups, although it is more common to find them disperse and in the medial zones linearly positioned at the periphery. They are the same size as a cutaneous pore, with a polygonal shape and radiolucent centre. They keep in a constant relation with each other, when similar projections are compared, even though these are obtained at different times (tattoo sign) (19) (arrow in Fig. 13, and Fig. 14a and b, pages 70 and 71) (Fig.14). Tangential projections with a metal marker will confirm the superficial location of these. Some deodorants, ointments or skin powders may leave traces that look like microcalcifications, as will be seen later in the miscellaneous item chapter (20).
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03. Cicatricial calcifications. During the first few months after a biopsy, tumorectomy or reductive procedures it is not uncommon to observe calcifications due mainly to dystrophic changes or fatty necrosis. These postoperative calcifications are located in the cicatricial bed, there being clear agreement in the mammographies if metal surface markers are used. Of varied morphology, in general pleomorphic and initially linear, these become coarser and larger in time. These dystrophic calcifications may simulate malignancy when they are small, irregular and grouped together. Calcifications of surgical sutures are linear, curvilinear or knot-shaped. Magnified and tangential projections will help to confirm the surface location of these and their benign nature (Fig. 15, page 72). 03. Microcystic Calcifications Microcycstic calcifications are a very common finding. These are annular calcifications (round with radiolucent centre) between 0.5 and 5 mm in size, single or multiple and generally represent microcysts by liponecrosis, although on other occasions their uncertain nature has been attributed to the presence of calcified intraductal cellular debris (21). One should remember that calcifications with radiolucent centres are always benign (Fig. 16, page 72).

ASYMMETRIES IN THE NORMAL CATEGORY 04. Asymmetries produced by normal parenchyma The asymmetry produced by normal mammary parenchyma is observed in 3% of normal breasts. It must meet the following characteristics: Being asymptomatic and non-palpable, Being located in the upper-outer quadrant or subareolar region (ductal asymmetry), Being isodense in respect of the neighbouring parenchyma and containing fat inside, Not being volumetric (need for a 3rd projection; focalised compression or standard with different obliquity), with no structural distortion, nor defined margins, nor grouped microcalcifications. Special mention should be given to the accessory mammary tissue in the axillary extension, which can be seen as an asymmetric density and as such can be the seat of both benign and malignant pathology (22) (Fig. 17, page 73). 04. Vascular asymmetry not associated with other signs The detection of vascular asymmetry, either in size or distribution, in a routine screening study is to be considered normal if the patient is asymptomatic and does not have any other mammographic anomalies. Accepting this as a normal variant, we must point out that their presence can be due to a different degree of compression when the mammographic study is made. Some of the pathological processes that cause vascular asymmetry are axillary or mediastinal tumorations which cause the development of collateral circulation through obstruction of the axillary, subclavian vein or superior vein cava (23) (Fig. 18, page 73). 04. Asymmetry of volume As a variant of normality there is overall mammary asymmetry. Postoperative changes (biopsy or tumorectomy) can create a glandular defect at the site of the excision and secondarily cause an asymmetric density of the normal tissue of the contralateral breast (Fig. 19, pag.74). ALTERATIONS OF THE SKIN/NIPPLE IN THE NORMAL CATEGORY 05. Cicatricial sequels of traumatisms, surgery or known and proven infection If the measures required for the nipple to be projected in profile in standard projections are not taken, this may simulate the presence of a subareolar mass (pseudonodule) in the mammography. Though this occurs very seldom, projections with anterior compression or focalised subareolar projections can solve the problem.
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Slight contusive type mammary traumatisms may cause subtle changes in the stroma with discrete trabecular and cutaneous thickening. If the traumatism was more severe, secondary steatonecrosis may cause cutaneous retraction (24). Benign scars, most of these postoperative, may give rise to cutaneous or nipple retraction. Benign inflammation which may give rise to cutaneous, focal or diffuse thickening will be dealt with in the chapter on the benign category.

Bibliography
1. 2. 3. Berkowitz JE, Gatewood OMB, Goldblum LE, Gayler BW. Hormonal replacement therapy: mammographic manifestations. Radiology 1990; 174: 199-201. Stomper PC, Van Voorhis BJ, Ravniker VA, Meyer JE. Mammographic changes associated with postmenopausal hormone replacement therapy: a longitudinal study. Radiology 1990; 174: 487-490. Lundstrom E, Wilczec B, Von Palffy Z, Soderqvist G, Von Schoultz B. Mammographic breast density during hormone replacement therapy: differences according to treatment. Am J Obstet Gynecol 1999; 181: 348-352. Ricciardi I, Ianniruberto A. Tamoxifen-induced regression of benign breast lesions. Obst Gynecol 1979; 51: 80-84. Homer MJ. Mammographic interpretation. A practical approach. New York: Mc Graw-Hill, 1977. Generalidad Valenciana. Conselleria de Sanitat.Programa de prevencin del cncer de mama en la Comunidad Valenciana. Monografia Sanitaria. Serie E. Nm.19. Valencia: Generalitat Valenciana, 1996. Svane G, Potchen EJ, Sierra A, Azavedo E. Stellate lesions. En: Patterson A. ed. Screening Mammography. Breast Cancer Diagnosis in Asymptomatic Women. St. Louis Mo: Mosby Year Book, 1993. Kolb TM, Lichy J, Newhouse JH. Occult cancer in women with dense breasts: detection with screening US- diagnostic yield and tumor characteristics. Radiology 1998; 207: 191-199. Cahill CL, Boulter PS, Gibbs NM, Price JL. Features of mammographically negative breast tumors. Br. J.Surg. 1981, 68 (12): 882-884. Egan RL, Mc Sweeney MB. Intrammamary lymph nodes. Cancer 1983; 51:1830-1842. Stomper PC, Leibowwich S, Meyer JE. The prevalence and distribution of well-circumscribed nodules on screening mammography analysis of 1500 mammograms. Breast Dis. 1991; 4:197-203. Lee CH, Giurescu ME, Philpotts LE, Horvath LI, Tocino I. Clinical importance of unilaterally enlarging lymph nodes on otherwise normal mammograms. Radiology 1997; 203: 329-334. Gordon PB, Gilks B. Sonographic appearance of normal intramammary lymph nodes. J Ultrasound Med 1988; 7: 545-548. Cardeosa G. Breast Imaging Companion. (2nd Edi). Lippincot: William&Wilkins, 2001 Shaw de Paredes E. Atlas de Mamografa. Madrid: Marban, 1994. Travade A, Isnard A, Gimbergues H. Imagerie de la pathologie mammaire. Paris: Masson, 1995. Huijung K, Greenberg, Javitt MC. Breast calcifications due to Mnkeberg medial calcific sclerosis. Radiographics 1999; 19: 1401-1403. Sickles EA. Breast calcifications. Mammographic evaluation. Radiology 1986; 160: 289-293. Homer MJ, DOrsi CJ, Sitzman SB. Dermal calcification in fixed orientation. The tattoo sign. Radiology 1983; 192: 592. Kopans DB, Meyer JE, Grabbe J. Dermal deposits mistaken for breast calcifications. Radiology 1983; 149: 592. Kopans DB. La mama en imagen. Madrid: Marban, 1994 Adler DD, Rebner M, Pennes DR. Accessory breast tissue in the axilla. Mammographic appearance. Radiology 1987; 163: 709. Carter MM, Mc Cook BM, Shoff MI. Case report: dilated mammary veins as a sign of superior vena cava obstruction. App. Radiol. 1987; 16: 100-102. Minagi H, Yonker JE. Roentgen appearance of fat necrosis in the breast. Radiology 1968; 90: 62-65.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

21

22

CHAPTER III CATEGORY 2. BENIGN


F. Martn Dez and M. Coll de la Vega

Introduction In the Benign category we will include lesions whose radiological characteristics make them unquestionably benign. These are consequently not going to generate any other procedure or diagnostic action (1, 2), even though they may require some kind of therapeutic intervention, as occurs with mastitis. Perhaps amongst all the mammographic categories in our procedure, the Benign group is the one involving greatest responsibility for the reader since, as we have already mentioned, the study ends here, with the woman being given an appointment for a further checkup two years later. On the other hand the Probably Benign, and of course the Probably Malignant and Malignant classifications inherently involve a new sequence of studies. It will sometimes prove difficult to consider a particular finding as being a lesion and we will therefore doubt whether to include this in the Normal or Benign categories, there being an overlapping area between these which is not actually important, since neither of them will require further studies, with the next checkup having to be made in the previously defined screening interval, which in the case of the VBCSP is every two years. Some examples: Small oval-shaped or not very dense nodule. Calcified liponecrosis and mastitis of plasmatic cells which could be included in either of the two categories, Normal or Benign (Fig. 1, page 77). Small calcified fibroadenoma. Sometimes, when in view of a particular radiological finding we consider a breast from the radiological standpoint of Probably Benign or even Probably Malignant, and this will thus entail a particular procedure, either a study with additional projections at the facility itself, a short-term follow-up or complementary studies to be performed in the reference hospital (ultrasound or biopsy) but after these, we conclude that these are benign lesions and thus in the following checkups these will then be included in the category of Benign in spite of their appearance. (3-6) A few examples might be of use: Nodule with a poorly defined contour which by ultrasound, or after the biopsy, draining of the liquid and pneumocystography, corresponds to a cyst (Fig. 2, page 77). Asymmetric zones which after follow-up remain stable, or after an ultrasound are proved to be a cyst. Group of probably benign microcalcifications with a 2-year follow-up, with no changes. Biopsied solid nodules or asymmetries with benign histological diagnosis. Star image with mammographies supplied by the patient from over 2 years before, in which this was already present. The characteristics of a cystic lesion in ultrasound are: anechoic, with a sharp contour and later reinforcement (Fig. 3 a and b, page 78). In our programme all the nodules that are studied by
23

ultrasound, solid and over 0.5 cm in size have to be considered as being in the probably benign category (7-9) (Fig. 4, page 79). In an initial sample of 61,009 examinations, the benign category includes 27% of the mammographies read in our programme, with a positive predictive value (PPV) of 0 for breast cancer. Of the 16,606 readings considered benign, 48.45% were nodules, 41.32% calcifications, 6.85% asymmetries, 0.2% structural alterations and in 3.16% of the cases the description of the lesion giving rise to this category was not given. The reading procedure at the VBCSP could seem to be excessively strict or stringent for a radiologist well-accustomed to mammographic reading, but it was prepared in an attempt to unify criteria amongst all the facilities, to avoid generating doubts and remove the subjective factor as far as possible. So, for example, we are aware that there are nodules over 0.5 cm in size but with perfectly well-defined contours in both projections, that are not very dense, allowing the rest of the parenchyma to be seen through these, even not being palpable to clinical examination, and we are sure that these are benign nodules, but by following our procedure strictly, as we will now see, we should consider these as being probably benign through their size (Fig. 5, page 79). Going by the VBCSP reading procedure, with the initial radiological reading we will consider these to be a Benign breast, when we find one of these Radiological Descriptions (10): NODULE/MASS IN THE BENIGN CATEGORY: According to their density these can be considered to be nodules with benign characteristics (2): 01. Water density: To consider a water density nodule as being benign, the following characteristics should be found: - Under 5 mm in diameter. - Low density, homogeneous and transparent. - Sharp contour in all the projections (Fig. 6, page 80). 01. Fatty density: Encapsulated lesions which are wholly radiolucent or which contain islets of mammary tissue are always benign (11): - Hamartoma or Fibroadenolipoma: tends to be easy to diagnose since this is characteristically seen as a mixed density mass through its double content in radiolucent fatty tissue and dense fibroadenomatous tissue, wrapped in a pseudocapsule, well-defined which was defined many years ago as a slice of salami (12) (Fig. 7, page 80). Sometimes the pseudocapsule can be difficult to identify and may even go unnoticed. - Lipoma: these are totally fatty lesions, surrounded by a fine capsule sometimes difficult to differentiate from the normal trabeculations in very fatty breasts. On the other hand, these are seen better in breasts with more glandular tissue, allowing one to see the distortion through occupation of space which they produce on the neighbouring structures, which sometimes mould them due to their low consistency (Fig. 8 a and b, page 81). The lipomas are thus soft and move freely, these being characteristics which may differentiate them from oily cysts and galactoceles, which are harder and rounded. - Galactocele. These are rounded, well-defined nodules, of fatty density, which could sometimes display a level if a middle-lateral projection is made (Fig. 9, page 82), and normally found in a retroareolar location. They tend to be produced in lactation periods or in women with high prolactin levels. - Oily cyst. This is the most frequent entity, normally due to post-traumatic fatty necrosis. They may be easy to detect clinically by palpation and on the other hand be difficult to show up in mammography (Fig. 10, page 82). We will also include in this section nodules considered benign when examined the second time round, since we know that after a first study in which these were included in a higher category, an ultrasound or a biopsy was made on them, or that they did not undergo changes after a series of short-term follow-ups as referred to earlier, so that from now on these nodules will thus be included in the Benign category.
24

C ATEGORY 2. B ENIGN

STRUCTURAL ALTERATION IN THE BENIGN CATEGORY: 02. Structural alteration due to traumatism, surgery or infection. The only structural alterations of the parenchyma that we can consider as being benign are due to postoperative (Fig. 11, page 83), post-traumatic, or post-infectious changes duly proven with over two years follow-up with no suspicious evolutionary changes; or if the patient supplies previous mammographies, also from over two years before, in which the finding was already detected, with no evolutionary changes (13). In successive series or reviews in which the same image persists we could nevertheless consider the mammography as being without findings, and thus include this in the Normal category. Though some authors consider that the typical star image with no dense central nucleus, even slightly fatty, with long, fine and homogeneous spicula, is characteristic of Sclerosing Ductal Hyperplasia or Radial Scar, we always consider this as being Probably Malignant, and it should never be included in the Benign category, unless there are prior studies from over two years before, no evolutionary change being observed (14). CALCIFICATIONS IN THE BENIGN CATEGORY: The deposits of calcium in the breast are extremely frequent, always establishing on some prior histological change (2). 03. Calcified fibroadenoma. Sometimes in dense breasts these are the only sign indicating that there is a fibroadenoma there (Fig. 12 a and b, pages 83 and 84). 03. Cystic liponecrosis. These are spherical calcifications produced by an inflammatory process with fatty saponification and later precipitation of the calcium (Fig. 13, page 84). 03. Granulomas on foreign bodies. This tends to occur in the case of sutures that have also been subjected to radiotherapy, morphologically seen as parallel calcifications with a tubular or polymorphous appearance (Fig. 14, page 85). 03. Ductal or periductal, very extensive through mastitis of plasmatic cells. These are positioned down the ductal lines, rarely branched and tend to have a diameter of over 0.5 mm. These are a form of secretory deposit, which will later be calcified, either in normal or dilated ducts, or in the periductal stroma by inflammatory reaction around them (Fig. 15, page 85). 03. Calcium milk in cyst. The calcium precipitates in the cystically dilated acini, coming out in the craniocaudal projection with a blurred, poorly defined or punctiform appearance which could start to be considered suspicious, but if the middle-lateral projection is made these will typically be observed deposited in the most sloping part in the shape of a half-moon, tea cup or simply linear (Fig. 16 a and b, page 86). The walls of the cysts can also calcify in the form of very fine annular deposits on a water density nodule, these being characteristics which differentiate them from calcifications of the fatty necrosis. 03. Disperse bilateral microcalcifications with a tendency to symmetrical distribution, and which do not form groups (Fig. 17, page 87). We should take great care not to overlook any small group of microcalcifications which is different and might represent some focus of malignancy. The microcalcifications which do not keep to a bilateral and symmetrical distribution should be examined with magnified projection (15). ASYMMETRIES IN THE BENIGN CATEGORY: 04. Asymmetries of the parenchyma. Any asymmetries of the parenchyma due to recent and clear clinical episodes such as traumatisms or infections which have conditioned the presence of asymmetries very probably due to haematomas

25

or abscesses can initially be considered as benign. But strictly speaking, the benign classification should only be given to the asymmetries of the parenchyma or ductal asymmetries which have displayed no alterations (Fig. 18 a and b, pages 87 and 88) after a follow-up of at least two years, over which they have been included in the Probably Benign category, or if at one of the checkups before this time, we find the typical images of post-traumatic fatty necrosis, or if the suspicious findings that entailed follow-up have simply disappeared. This is to say that, to do things properly, any asymmetry should be considered with the initial radiological reading as at least Probably Benign, carrying out a physical examination and/or ultrasound. On other occasions it would be possible to avoid the follow-up of an asymmetry zone which - we insist - is Probably Benign from the initial mammographic reading, if an ultrasound is performed in which unquestionably benign findings are seen, such as for example a zone with diverse small cystic formations, or if an FNAB or core needle biopsy is made of the zone, directed by ultrasound, taking several samples, and if the report, preferably a histological one, has unquestionably benign findings (16) (Fig. 19 a and b, pages 88 and 89). Nevertheless, any asymmetry which meets the following conditions can be considered Benign or even Normal right from the start: if this is not palpable (any asymmetry must be clinically examined) located preferably in the upper-outer quadrants, having a density similar to the rest of the parenchyma, even if it contains zones of fatty density, and is not volumetric, that is if this is only observed in a projection, or disappears with spot compression (17, 18). ALTERATIONS OF THE SKIN/NIPPLE IN THE BENIGN CATEGORY: 05. The thickenings of the skin can be of local or general nature (19). Amongst the most frequent causes of local thickening of the skin we can find the local infection (with or without abscess-forming), the traumatism and postoperative scar (Fig. 20 a and b, pages 89 and 90). Diffuse thickenings of the skin are more frequent, associated with generalised oedema which must be due to both aseptic and bacterial mastitis (Fig. 21, page 90) or to prior radiotherapy. The syndrome of diffuse and bilateral oedema-thickened skin tends to arise through a dermatological cause, congestive heart failure or kidney failure. The greatest difficult is involved in being able to differentiate Mastitis from Inflammatory Carcinoma and Pagets carcinoma from simple eczema of the nipple, as described in the chapter on the Malignant category. COMBINED/MULTIPLE: 06. This radiological description is included to describe two specific situations: - To explain why two or more findings previously described with benign characteristics are present in the same lesion (this is normally a nodule with calcifications). In this case the two findings combined which will previously have been stated along with the relevant code, will have been separately analysed and both considered benign (Fig. 22, page 91). - Because one of these findings, of benign characteristics, which will also have been reflected beforehand with its corresponding code, is observed in large numbers in the same breast; for example, the multiple nodules of benign characteristics with numerous cysts (Fig. 23, page 91) and/or fibroadenomas. OTHERS: 07. We will mainly use this description to take note that there is some other finding in the mammography which is not the one giving rise to the classification in the benign category but which should be included in a lower group, that is in the Normal category; for example, a breast with typically benign calcifications which also has normal vascular calcifications (Fig. 24, page 92).

26

C ATEGORY 2. B ENIGN

Bibliography
1. 2. 3. 4. 5. Shaw de Paredes E. Evaluation of abnormal screening mammograms. Cancer 1994; 74: 342-349. Homer M. Benign lesions in the breast. In: Mammographic interpretation. A practical approach. New York. Mc Graw-Hill 1991; 30-56. Sickles EA. Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases. Radiology 1991; 179: 463-468. Sadowsky NL, Semine AA, Levin E, Kelly E. Ultrasonographic guidance for needle biopsy of breast lesions. Surg Oncol Clin North Am 1997; 6: 265-84. Vizcaino I, Gadea L, Andreo L, Salas D, Ruiz-Perales F, Cuevas D,et al. Sreening Program Working Group. Short-term follow-up results in 795 nonpalpable probably benign lesions detected at sreening mammography. Radiology 2001; 219 (2): 475-83 Apesteguia L, Pina L, Inchusta M, Mellado M, Franquet T, De Miguel C, et al. Nonpalpable, well-defined, probably benign breast nodule: management by fine-needle aspiration biopsy and long-interval follow-up mammography. Eur Radiol 1997; 7 (8): 1235-9 Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology. 1995; 196: 123-134. Schepps B, Scola FH, Frates RE. Benign circumscribed breast masses. Mammographic and sonographic appearance. Obstet Gynecol Clin North Am 1994; 21: 519-537. Fornage B, Lorigan J, Andry E. Fibroadenoma of the breast: Sonographic appearance. Radiology 1989; 172: 671-675. Generalidad Valenciana. Conselleria de Sanitat. Programa de Prevencin de Cncer de Mama en la Comunidad Valenciana. Monografa Sanitaria Serie E, n19. Valencia: Generalitat Valenciana 1996. Kopans DB. Lesiones benignas y probablemente benignas. En: La mama en imagen. Madrid: Marban 1999; 353-356. Riveros M, Cubilla A, Perotta F, Solalinde V. Hamartoma of the breast. J Surg Oncol 1989; 42: 197-200. Stigers KB, King JG, Davery DD, Stelling CB. Abnormalities of the breast caused by biopsy: spectrum of mamographic findings. AJR 1991; 156: 287-291. Alleva DQ, Smetherman DH, Farr GH, Cederbom GJ. Radial scar of the breast: radiologic-pathologic correlation in 22 cases. Radiographics 1999; 19: S27-S35; discussion S36-7. Lafontan B, Daures JP, Salicru B, Eynius F, Mihura J, Rouanet P et al. Isolated clustered microcalcifications: diagnostic value of mammography, series of 400 cases with surgical verification. Radiology 1994; 190: 479-483. Fuhrman G, Cederbom G, Champagne J, Farr G, McKinnon W, Bolton J et al. Stereotactic core needle breast biopsy is an accurate diagnostic technique to assess nonpalpable mammographic abnormalities. J La State Med Soc 1996; 148: 167-70. Homer M. Localizing signs of breast cancer, en: Mammographic interpretation. A practical approach. New York: Mc Graw-Hill, 1991; 47-54. Kopans DB, Swann CA, White G et al. Asymmetric breast tissue. Radiology 1989; 171: 639-43. Kopans DB. Hallazgos asociados: cambios en la piel, pezn y trabculas y adenopatas axilares. In: La mama en imagen. Madrid: Ed. Marban 1999; 339-341.

6.

7. 8. 9. 10. 11. 12. 13. 14. 15.

16.

17. 18. 19.

27

28

CHAPTER IV CATEGORY 3. PROBABLY BENIGN


I. Vizcano Esteve

Introduction. Probably benign lesions are described in the reading systems of the VBCSP (1, 2) as non-palpable lesions which have a low risk of cancer with a Positive Predictive Value (PPV) ranging from 0.3 to 1.7% (2-7). This category represents a percentage ranging from 2 to 11% of all mammographic readings in the first screening round (3-7). According to the readers training level and experience there will be a greater percentage of probably benign lesions at the start of the readings, which will drop with experience, and with the availability of prior mammographies in the second and successive rounds. (7, 8). Sickles defines probably benign lesions as the non-palpable findings in which a short mammographic follow-up (under the screening interval) is recommended as an alternative to open surgical biopsy or percutaneous fine or core needle biopsy (8). The probably benign category should not be included in the positive findings of screening, this being rather a category close to benignity, but in which the presence of a few malignant lesions means that benignity should be confirmed, by means of a short mammographic follow-up, generally from 6 to 12 months after the initial screening (7,8). If the lesion grows the procedure should be to go on to complete excisional surgical biopsy (3-7). Prior to classifying a lesion in the probably benign category, this should be studied by means of localised projections in the case of nodules and asymmetries, and with magnified projection for microcalcifications. Later on, depending on the type of lesion, an additional valuation defined by the clinical examination (9) and the ultrasound (10) can be made. In certain cases definitive normality or benignity can be established, including the lesions in the relevant categories of 1. NORMAL and 2. BENIGN. Given the amount of variables to consider in the mammographic signs, certain inaccuracies are involved in determining the classification of a lesion as probably benign, nevertheless we have adopted the following criteria, based on both the publications existing and on our own data obtained at the VBCSP (3-7): 01. NODULES IN THE PROBABLY BENIGN CATEGORY: Non-calcified nodules of any size, in general of 0.5-2 cm, non-palpable, round, oval or lobulated (with 2 or 3 lobulations) with sharp well-defined contours, fully or partially visible due to superimposing with the glandular tissue surrounding them, with no fat inside, with or without a halo sign (Fig. 5, page 79; 1 a, page 95; 2 a, page 96; and 3, page 97). Ultrasound is recommended as first valuation of nodules, as this is able to demonstrate the presence of cysts (Fig. 3 b, page 78) or solid lesions with echographic characteristics of benignity (Fig. 4, page 79; 1 b, page 95; 2 b, page 96). Occasionally, intracystic lesions requiring later cytological or histological study can be revealed by means of ultrasound (Fig. 4, page 97).
29

02. CALCIFICATIONS IN THE PROBABLY BENIGN CATEGORY: Grouped microcalcifications. The following are considered to be characters of probable benignity: - Forming fairly small groups (of 5-10 particles). - Spherical, round or oval with well-defined contours (Fig. 5, page 98). - Homogeneous in shape, size and density, though it also includes any that reveal variations in size and density (Fig. 6, page 98). We include in this section punctiform microcalcification and groups of small, amorphous, flaky or blurred micro-calcifications (Fig. 7, page 99). The descriptions of microcalcifications that are combinations of the previous ones that cannot be considered as being definitively benign, that are indeterminate or difficult to classify, but with an absence of signs of malignancy, have also been included in this category (Fig. 8 a and b, pages 99 and 100). 03. ASYMMETRY IN THE PROBABLY BENIGN CATEGORY: 3.1. Asymmetries of the parenchyma, focal, similar to the adjacent parenchyma, with a volumetric effect (visible in two projections) and which are not modified with spot compression, with no fat interspersed in these and without the mass effect or associated structural alteration. Generally located in areas other than the areolar region or the upper-outer quadrant of the breast. These are considered to be included in this section when they do not comply with the conditions stated in the asymmetries of a benign nature or in the asymmetries defined as being probably malignant, recently appearing or in relation to HRT (Fig. 9 a and b, pages 100 and 101). Asymmetries should always be valued by means of palpation and ultrasound. When these are palpable and the ultrasound reveals a mass one should proceed to percutaneous biopsy (Fig. 10 a and b, pages 101 and 102). 3.2. The asymmetric ductal pattern, viewed as tubular images from the nipple, is also included in this category. The ultrasound, or the galactography can on occasions reveal the cause of ductal asymmetry (Fig. 11 a and b, pages 102 and 103). Ductal asymmetries should also always be valued by palpation. 06. COMBINED / MULTIPLE Includes all possible combinations of probably benign findings, or of the unilateral or bilateral presence of probably benign, isolated or combined findings. Examples of this are multiple lesions (more than 2) and/or bilateral lesions consisting of nodules (Fig. 12, page 103). Disperse microcalcifications (Fig. 13, page 104), or in multiple groups (Fig. 6, page 98) unilateral or bilateral consisting of particles of the same characteristics are included as benign lesions, and do not have to be followed up in the short term, since in our series (7) and in other similar ones published (6) no case of malignancy has been detected. Disperse unilateral or bilateral microcalcifications pose a perception problem, meaning that special attention should be given to reviewing these so as not to confuse any group of different characteristics that could represent malignancy. When there is a combination of these descriptions or simultaneous presence of lesions these are classified by the most outstanding finding, although each lesion should be individually valued. 07. OTHERS Includes any additional finding not covered under the normal or benign category which is found at the same time as probably benign findings. Conduct generating the probably benign category Unlike the BIRADS reading system (11), in which after completing the study with image, complementary projections and ultrasound, if the lesion is considered as being probably benign this is synonymous of a mammographic follow-up in the short term, in our reading system we consider the initial mammographic reading (a double reading with consensus) plus the complementary projections for classification of a lesion in the probably benign category with the criteria described in sections 01, 03, 04 and 06, always having to follow-up the study of the lesion from this classification,
30

C ATEGORY 3. P ROBABLY B ENIGN

with the possibility of making an ultrasound and a later follow-up in the short term (for example: short-term follow-up at six months for a solid nodule with benign characteristics in both mammography and ultrasound). Any probably benign lesion should be followed-up to establish definitive benignity. At the VBCSP a short-term follow-up procedure of two checkups between rounds at six and twelve months is at present recommended (7), proceeding to surgical biopsy in the event of growth of the lesion (Fig. 14 a and b, pages 104 and 105). One must take into account that certain calcifications can remain stable in these periods of time and be a carcinoma, which is why surgical biopsy would also be recommended when later modification or growth is seen after the short-term follow-up periods (15) (Fig. 15 a and b, pages 105 and 106). Multiple nodules (solid in ultrasound) probably benign, unilateral or bilateral, with similar characteristics, are also valued with a short mammographic follow-up to establish their definitive benignity. Fine-needle biopsy, guided by stereotaxis, coordinates or ultrasound could be useful in particular probably benign lesions (16-18) (Fig. 3 page 97; 16 a, b and c, pages 106 y 107), though it has been proved that the use of a short-term mammographic follow-up is a useful alternative to value such lesions, with no need to use percutaneous cytological or histological samples (7, 8). Asymmetries in density originally classified as probably benign should always be studied by means of palpation and ultrasound to objectify/ discard mass, making a later cytological or histological study if required, and are never included in the short-term follow-up procedure (Fig. 17 a and b, page 108). The use of core needle biopsy has been suggested in probably benign lesions in women who for different reasons cannot follow-up the short-term checkups, or who themselves request a histological analysis (19), but the cost-effectiveness ratio of this technique in these low risk lesions is being questioned (20). The microcalcifications defined by us as probably benign lesions constitute a very heterogeneous group which is at present being reviewed to correlate the histological findings, as the benign calcifications also progress in the short-term follow-up and require surgical excision reducing the PPV of the biopsies (Fig. 8 a and b, pages 99 and 100) (7). According to our experience in a valuation of 13,790 women at the VBCSP, studied in the first round of the screening, the lesions classified as probably benign came to 795 (5.8% of the total of women screened), of which 242 (31%) were nodules, 471 (59%) microcalcifications and 82 (10%) asymmetries, and the PPV of these probably benign lesions was 0.3% (7).

Bibliography
1. 2. 3. 4. 5. 6. 7. Generalidad Valencia. Conselleria de Sanitat. Programa de Prevencin de Cncer de Mama de la Comunidad Valenciana. Monografa Sanitaria Serie E, n 25. Valencia: Generalitat Valenciana 1998. Vizcano I, Salas D, Vilar JS, Ruiz-Perales F, Herranz C, Ibaez J et al. Breast Cancer Screening: First Round in the population-based Program in Valencia, Spain. Radiology 1998; 206: 253-260. Sickles EA. Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases. Radiology 1991; 179: 463-468. Wolfe JN, Buck KA, Salane M, Parek NJ. Xeroradiography of the breast: overview of 21,057 consecutive cases. Radiology 1987; 165: 305-311. Helvie MA, Pennes DR, Rebner M, Adler DD. Mammographic follow-up of low-suspicion lesions: compliance rate and diagnostic yield. Radiology 1991; 178: 155-158. Varax X, Leborgne F, Leborgne JH. Nonpalpable, probably benign lesions: role of follow-up mammography. Radiology 1992; 184: 409-414. Vizcaino I, Gadea L, Andreo L, Salas D, Ruiz-Perales F, Cuevas D, et al. Screening Program Working Group. Short-term follow-up results in 795 nonpalpable probably benign lesions detected at screening mammography. Radiology 2001; 219 (2): 475-83 Sikles EA. Probably benign lesions: when should follow-up be recommended and what is the optimal follow-up protocol? Radiology 1999; 213: 11-14. Homer MJ. Imaging features and management of characteristically benign and probably benign breast lesions. Radiol Clin North Am 1987; 5: 939-951.
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8. 9.

10. Cilotti A, Bagnolesi P, Moretti M, et al. Comparison of the diagnostic performance of high-frequency ultrasound as a first- or second-line diagnostic tool in non-palpable lesions of the breast. Eur Radiol 1997; 7: 1240-1244. 11. American College of Radiology (ACR). Breast Imaging reporting and data system (BI-RADS). Third Edition. Reston [VA]: American College of Radiology; 1998. 12. Brenner RJ, Sickles EA. Acceptability of periodic follow-up as an alternative to biopsy for mammographically detected lesions interpreted as probably benign. Radiology 1989; 171: 645-646. 13. Sickles EA. Management of probably benign breast lesions. Radiol Clin North Am 1995; 6: 1123-1130. 14. Dawson JS, Wilson ARM. Short-term recall for probably benign mammographic lesions detected in a three yearly screening programme. Clinical Radiology 1994; 49: 391-395. 15. Hall FM, Homer MJ. Mammographic follow-up of clustered microcalcifications. A letter to editor and reply in AJR 1995; 1550-1551. 16. Apestegua L. Pina L. Inchusta M et al. Nonpalpable, well-defined, probably benign breast nodule: management by fine-needle aspiration biopsy and long-interval follow-up mammography. Eur Radiol 1997; 7: 1235-1239. 17. Azavedo E. Svane G. Auer G. Stereotactic fine-needle biopsy in 2594 mammographically detected nonpalpable lesions. Lancet 1989; 1033-1036. 18. Fornage BD. Guided fine-needle aspiration biopsy of non-palpable breast lesions: calculation of accuracy values. (Letter to Editor). Radiology 1990; 3: 884-885. 19. Sickles EA, Parker SH. Appropriate role of core breast biopsy In the management of probably benign lesions (editorial). Radiology 1993; 188:315. 20. Brenner RJ, Sickles EA. Surveillance mammography and stereotactic core breast biopsy for probably benign lesions: a cost comparison analysis. Acad Radiol 1997; 4: 419-425.

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CHAPTER V CATEGORY 4. PROBABLY MALIGNANT


L.A. Andreo Hernndez, L. Gadea Boronat, MJ. Fuster Selva, C. Ort Tarazona and F. Ardoy Ibez.
Introduction Category 4 refers to lesions with mammographic findings very suspicious of malignancy, although the image and the pathological anatomy cannot be fully correlated, since this appearance can be found, albeit more seldom, in benign lesions (1). In our Programme, on an initial sample of 61,009 mammographic examinations, 155 (0.25%) were put into this category. The lesions should have what we call the volume effect, that is, these should be seen to have a three-dimensional structure recognisable in two projections, since the superimposing of normal breast structures can take on the suspicious appearance of a false star or nodule. Further projections such as spot compression or magnification help to confirm the existence of the lesion, and to decide as to its possible suspiciously malignant appearance (2). One of the suspicious characteristics may only prove to be visible in one of the projections made, as occurs in some cases of partially poorly defined contour or in rare cases of masses or flat lesions in star-form, which may reveal a smaller diameter in one of the projections (Fig. 1 a and b, page 111). Here too localised mammographies and further projections are of use, or rotating the breast clockwise or anti-clockwise (3). When we say that an image is probably malignant we are stating that this is a lesion for which we must in all cases obtain a histopathological diagnosis. The mammographic differentiation between benign and malignant lesion depends to a large extent on the readers experience and the strictness in the interpretation of the lesions included in this section (4,5). In the initial activity of our Programme (1992) the PPV for the probably malignant category was 46.57%, that is, a cancer was diagnosed in practically one of every two cases in which this reading was made. The procedure to be used to come to the diagnosis will depend on the type of lesion, being in general preferable, whenever this is possible to carry out biopsy since these are lesions which involve a high probability of malignity. As to the method used for obtaining the sample, core biopsy or FNAB, there is no unanimous agreement (6-9), depending in many cases on the availability of the technical and human resources at each facility, as well as the location and characteristics of the lesion. We will now go over the Radiological Descriptions of the lesions classified in the Probably Malignant category (1). NODULES IN THE PROBABLY MALIGNANT CATEGORY: 01. Nodules/Masses. We use the probably malignant classification for nodules of any size, generally of high density, which have a poorly defined, spiculated, irregular, polylobulated or microlobulated appearance (Fig. 2, page 112), and which may or may not have an extension in comet-tail shape (Fig. 3, page 112). In our screening programme nodules or masses made up 44.5% of the probably malignant lesions, either as nodules with an irregular (27.7%) or spiculated (16.7%) contour.
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Finding a nodule in a screening mammography is always relevant, and its nature should be accurately determined. First of all there has to be a systematic analysis of its characteristics to classify this in one of the categories diagnosed and mark out a later approach. Some of these characteristics are the size, location and density, as well as the shape. But particular importance must be given to analysing the contour, as when this is poorly defined or spiculated there is a high risk of the lesion being malignant (10). The presence of longer or shorter spicula at the edge of the lesion is a particularly suspicious sign. When the spicula are small-sized these are called brush-edged (Fig. 4, page 113). At times it occurs that spiculation in the contour of a nodule is not similarly apparent in all the projections, which is the reason for the importance of the double projection and of the further projections, whenever something suspicious is seen at the edge of a nodular lesion (Fig. 5 a and b, pages 113 and 114). One must furthermore bear in mind that the blurredness, irregularity, spiculation or poor definition of one part of the contour, confirmed by several projections and with spot compression, is already a criterion for classifying this as Probably Malignant (Fig. 6 a and b, pages 114 and 115). This category therefore includes all the nodules or masses with a spiculated (Fig. 7 a and b, pages 115 and 116), or ill-defined contour (Fig. 8, page 116), whatever their size, density or shape is. When a nodule is small-sized or is found in a dense breast which partially conceals this, spot compression with or without magnification may improve viewing of its edges (Fig. 9 a and b, page 117). Large palpable nodules with spiculated contours should be considered as being in the Malignant category even though these are the only sign. Some benign pathologies may display poorly defined contours and even spiculation, such as cicatricial fibrosis, fatty necrosis, elastosis and infrequent tumours such as extra-abdominal desmoids and granular cell tumours (11). Nevertheless there is no mammographic sign allowing a differentiation to be made between these lesions and a malignant neoplasia, which is why, as previously said, the finding of a nodule of these characteristics requires a biopsy to be made in all cases. Lobulated contour nodules, especially when the lobulations are numerous and small, also involve a high degree of suspiciousness of malignancy (10), the microlobulated contour having been associated with high mucin content tumours (12) (Fig. 10, page 118). Other signs may be found in connection with the desmoplastic effect of malignant tumours, such as the retraction of the surrounding parenchyma or a comet-tail extension (Fig. 3, page 112). As regards density, it is important to bear in mind that this depends to a large extent on the size of the tumour, and that it is not infrequent to find small sized and low density malignant tumours (Fig. 11 a and b, page 119). Although the malignant nodules are generally denser than the benignant ones of the same size (13), this characteristic is not a determining factor in the approach to be taken which is why, for example, a recently appearing low-density solid nodule should be biopsied. It is important to remember that some malignant tumours may occasionally have a well-defined contour, examples of these being the mucinous or colloid carcinoma (Fig. 12, page 120), the medullary, papillary and ductal carcinoma (14), and that the ultrasound and the FNAB are ideal techniques for studying the nature of these lesions.

STRUCTURAL ALTERATION IN THE PROBABLY MALIGNANT CATEGORY: 02. Stars. When the mammographic finding is an alteration of the structure in a star-shape this is always classified as being a probably malignant lesion (Fig. 13, page 120). A star shaped lesion is an area of distortion of the mammary architecture with irregular edges and which takes on a radiated morphology, with no central tumoral nucleus. This is a mammographic finding which can be a consequence of a great variety of processes, both benign and malignant, the most frequent ones being carcinoma, the radial scar, sclerosing adenosis, fatty necrosis and postoperative alterations, apart from the infectious pathology (4, 15). The 4.7 % of the images read as probably malignant at the VBCSP were stars. Since most of the structural alterations in star form are malignant neoplasias and that mammographic criteria of benignity and malignancy do not allow a specific diagnosis, we classify these lesions as being probably malignant in all cases, thus requiring a biopsy (16). As was said above
34

C ATEGORY 4. P ROBABLY M ALIGNANT

on the matter of Benign lesions, only when there is a documented traumatic or surgical record with mammographies can a conservative approach be taken by mammographic control. In dense breasts it may occur that the distortion is appreciated without the radiated morphology being clearly seen, meaning that it is very useful to use spot compression, which will display the star in many cases (Fig. 14 a and b, page 121). 02. The structural alteration of the breast architecture may be found in a zone with no associated mass. The mammographic finding is subtle and may go unnoticed if the different projections are not thoroughly and symmetrically compared. The most common cause of architectural structural alteration with no mass is postoperative scarring, and the most important differential diagnosis carcinoma, especially infiltrating lobular carcinoma (17) (Fig. 15 a, b and c, pages 122 and 123). CALCIFICATIONS IN THE PROBABLY MALIGNANT CATEGORY: 03. Microcalcifications. Microcalcification is the term given to calcifications of under 0.5 mm in size (18), and often an early sign of breast cancer, which turns them into a finding of great importance in the screening mammography. The microcalcifications with characteristics of malignancy, grouped or with regional or segmentary distribution, heterogeneous in shape, size and density, intraductal, vermiform, granular, with irregular contour and poorly defined, are classified as probably malignant. In our case they made up 16.8% of the lesions read as probably malignant. In population screening studies, 90% of the non-palpable in situ carcinomas and 70% of the carcinomas under 0.5 cm in size could be detected thanks to viewing microcalcifications as the only sign (19, 20). Due to their small size it is essential to obtain magnified mammographies in order to make a proper analysis of their morphology (21, 22), to allow them to be attributed to the probably malignant category (23) (Fig. 16 a and b, pages 123 and 124). Calcifications which we can consider typical of breast cancer are small, in groups and with a linear, curved or ramified morphology (18) (Fig. 17, page 124). The pleomorphic appearance of the groups is an important fact, given that malignant calcifications tend to display marked heterogeneity as regards shape, size and density (Figs. 18 and 19, page 125). In a study of 400 cases of microcalcifications B. de Lafontan and colleagues saw that this criterion of pleomorphism, along with the vermicular and ramified or linear morphology, allowed 90% of carcinomas to be properly diagnosed (24). Distribution is not a definitive criterion for assigning a high or low degree of suspicion, although groups - above all when these are highly numerous and small, granular (Fig. 20, page 126), and a segmentary distribution suggesting calcium deposits in a duct and its branches - raise the level of suspiciousness and should make one value the possibility of a biopsy (Fig. 21 and 22, pages 126 and 127). When these deposits are very numerous, affecting a large part of the breast, with very diverse shapes, sizes and density of the calcifications, these should be classified as malignant category lesions. In screening mammography the concept of stability is important, meaning that if an image does not change its appearance over time, we can assume that this is a benign process. Cases have nevertheless been described of stable malignant microcalcifications in a follow-up of over 5 years, this being more frequent in the in situ ductal carcinoma than in infiltrating carcinoma (25). Similarly, the increase in size of calcifications or the appearance of new ones does not necessarily imply malignancy, as this may occur in benign lesions such as adenosis. Therefore, whilst still being important, the stability of microcalcifications is not a definite factor in every case, the analysis of the shape and distribution of these being more decisive (22). ASYMMETRY IN THE PROBABLY MALIGNANT CATEGORY: 04. Tumoral asymmetry. Tumoral type asymmetrical densities, with mass effect, associated with structural alteration or malignant type microcalcifications (Fig. 23 a and b, page 127 and 128) are considered to be probably malignant asymmetries. Although tissular asymmetry is a very frequent finding, generally these are fibroglandular remains, without exploratory findings or tumoral appearance. The asymmetry of tumoral appearance is a rare finding (26), only representing 1.3% of the lesions of this category (Fig. 24, page 128), and tends to
35

be seen as a tumour, palpable or not, located in a zone where it is not customary to find tissular remains (4). The procedure to be implemented in view of a suspicious asymmetry depends on its clinical presentation, and in all cases a physical examination of the breast should be made as first step. If the asymmetry is palpable a sample should be taken of this. In the event of a non-palpable asymmetry visible in ultrasound, this can be used as guidance for performing a FNAB or core biopsy (27) (Fig. 25 a, b and c, pages 129 and 130). COMBINED/MULTIPLE: 06. This section includes the simultaneous unilateral or bilateral presentation of isolated, probably malignant findings. The joint presentation of several probably malignant lesions, such as a star with microcalcifications and cutaneous retraction, for example, is considered to be a malignant lesion, which is why it is not included in this description. There are nevertheless times when these findings are faint, involving a combination of signs which may be classified as probably malignant, depending on the readers experience. On these occasions one cannot be sure that the lesion is malignant even though this appears in combination, and it should thus be included in this category. In most cases, this involves the appearance in one or both breasts of two or more lesions, each of which can be classified as probably malignant, whether these be stars, nodules or groups of microcalcifications. One must bear in mind that in nearly 15% of cases the carcinoma is multifocal or multicentral at the time of its mammographic detection (28) (Fig. 26, page 130). OTHERS: 07. As occurs with the other categories, this section includes the findings of normal, benign or probably benign categories, which are presented simultaneously with the probably malignant findings. To make as complete a reading as possible of the mammography note is taken of these findings of lesser pathological importance under the heading 07. Others. Conduct generated by the probably malignant category As mentioned, reading a lesion as probably malignant implies in all cases getting a procedure under way to enable a histological sample of this to be obtained. The woman should be sent to the Reference Hospital to have the histopathological diagnosis made. With the precautions previously stated, and bearing in mind that each case must be studied individually, general patterns of action can be established according to the mammographic image involved: - Nodule/mass. A FNAB or core biopsy is carried out and in the event of the item not being palpable this will be guided by ultrasound. In the rare cases in which the nodule is not palpable and is not visible echographically either, biopsy or FNAB by stereotaxy or surgical biopsy after location with a harpoon or hookwire will be appropriate options. - Stars. An excisional biopsy should always be performed, since we do not have any guarantee of getting a suitable sample of the lesion when a core biopsy is made and even less with a FNAB. - Microcalcifications. In this case, through being generally non-palpable lesions, the alternatives are excisional biopsy and core biopsy guided by stereotaxy. - Asymmetries. If the asymmetry is palpable a FNAB or a core biopsy should be performed. If this is not so, it will depend on whether this is echographically visible, in which case a FNAB or guided core biopsy should be attempted, When the lesion is not palpable nor echographically visible one has to resort to an excisional biopsy by means of pre-surgery location. N.B. All the cases described in the figures of this chapter correspond to histologically proven carcinomas.

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Bibliography
1. 2. 3. 4. 5. Generalidad Valenciana. Conselleria de Sanitat. Programa de Prevencin de Cncer de Mama en la Comunidad Valenciana. Monografa Sanitaria. Serie E, n25. Valencia: Generalitat Valenciana.1998. Shaw de Paredes E. Radiographic Breast Anatomy: Radiological Signs of Breast Cancer. RSNA Categorical Course in Physics Technical Aspects of Breast Imaging. Syllabus 1992; 31-42. Kimme-Smith C, Bassett LW, Gold RH. Workbook for Quality Mammography. Baltimore: Williams & Wilkins. 1992. Homer MJ. Mammographic interpretation. A Practical approach. Day W, Navrozov M, eds. New York. Mc Graw-Hill Inc.1991. Svane G, Potchen EJ, Sierra A, Azavedo E. How to Interpret a Mammogram. En: Patterson A, ed. Screening Mammography: breast cancer diagnosis in asymptomatic women. St. Louis Mo: Mosby Year Book, 1993; 153. Evans, WP. Stereotaxic Fine-Needle Aspiration and Core Biopsy. RSNA Categorical Course in Breast Imaging. Syllabus 1995; 151-160. Parker SH, Burbank F, Jackman RJ, Aucreman CJ, Cardenosa G, Cink TM et al. Percutaneous large-core breast biopsy: a multi-institutional study. Radiology 1994; 193: 359-364. Dowlatshahi K, Yaremko ML, Kluskens LF, Jokich PM. Nonpalpable breast lesions: findings of stereotaxic needle-core biopsy and fine-needle aspiration cytology. Radiology 1991; 181: 745-750. Dershaw DD. Stereotaxic Breast Biopsy. Semin Ultrasound, CT MR 1996; 17: 444-459. Adler DD. Mammographic Evaluation of Masses. RSNA Categorical Course in Breast Imaging. Syllabus 1995; 107-116. Kopans DB. Breast Imaging. Philadelphia: Lippincott Company, 1993. Conant EF, Dillon RL, Palazzo J, Ehrlich SM, Feig SA. Imaging findings in mucin-containing carcinomas of the breast: correlation with pathologic features. AJR 1994; 168: 821-824. Jakson V, Dines KA, Bassett LW, Gold RH, Reynolds HE. Diagnostic importance of the radiographic density of noncalcified breast: analysis of 91 lesions. AJR 1991; 157: 25-28. Bassett LW, Jahanshahi R, Gold RH, Fu YS. Film-Screen Mammography. An Atlas of instructional cases. London: Dunitz 1991. Tabr L, Dean PB. Teaching atlas of Mammography. Stuttgart. Thieme Verlag 1983. Svane G, Potchen EJ, Sierra A, Azavedo E. Stellate lesions. In: Patterson A. ed. Screening Mammography. Breast Cancer Diagnosis in Asymptomatic Women. St. Louis Mo: Mosby Year Book, 1993. Andersson I. Introduction to Mammography. Sweden; NICER Publication 1992. Sickles EA. Breast calcifications: mammographic evaluation. Radiology 1986; 160: 289-293. Feig SA, Shaber GS, Patchefsky A. Analysis of clinically occult and mammographically occult breast tumors. AJR 1974; 121: 846-853. Moskowitz M. The predictive value of certain mammographic signs in screening for breast cancer. Cancer 1983; 51: 1007-1011. Sickles EA. Further experience with microfocal spot magnification mammography in the assessment of clustered breast microcalcifications. Radiology 1980; 137: 9. Feig SA. Mammographic evaluation of calcifications. RSNA Categorical Course in Breast Imaging. Syllabus 1995; 93-105. Haehnel P, Kleitz C, Looringhe GC. Mammographical Magnification. Imaging of the Breast: an Update. Categorical Course ECR93. Syllabus 1993; 29-32. Lafontan B, Daures JP, Salicru B, Eynius F, Mihura J, Rouanet P et al. Isolated clustered microcalcifications: Diagnostic value of mammography-series of 400 cases with surgical verification. Radiology 1994; 190: 479-483. Lev-Toaff AS, Feig SA, Saitas VL, Finkel GC, Schwartz GF. Stability of malignant breast microcalcifications. Radiology 1994; 192: 153-156. Adler DD, Helvie MA, Ikeda DM. Nonpalpable, probably benign breast lesions: Follow-up strategies after initial detection on Mammography. AJR 1990; 155: 1195-1201. Jackson VP, Reynolds HE, Hawes DR. Sonography of the Breast. Semin Ultrasound, CT MR 1996; 17: 460-475. Sickles EA. Mammographic features of 300 consecutives nonpalpable breast cancers. AJR 1986; 146: 661-663.

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

25. 26. 27. 28.

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38

CHAPTER VI CATEGORY 5. MALIGNANT


F. Ruiz Perales, A. Hernndez Jimnez and M. Montes Avila.

Introduction This category includes images which are the combination of probably malignant lesions associated with one another and also simple or combined probably malignant lesions, with thickening or retraction of the skin, nipple or pectoral muscle. Single lesions whose size and morphology involve clear signs of malignancy should also be included in this category. We refer mainly to high density spiculated masses and to widespread diverse microcalcifications with morphological characteristics of malignancy. Also included in this category are the associations of a probably malignant or malignant lesion with the presence of axillary adenopathies whose size, density, morphology or contours mean that these are considered pathological. Although womens participation in a screening programme requires that these should be asymptomatic, this requirement is sometimes more theoretical than real, for many causes, one of the most frequent of these being a lack of health information, which means that some women have undervalued their symptoms, interpreted these wrongly or not given them due importance. Some of the cancers included in this category are clinical, above all the ones involving alterations of skin and nipple. These involve clinical signs that are sometimes subtle and revealed through the operations carried out during clinical examination but that are on other occasions very evident. In this category we include inflammatory carcinoma, which develops with signs in the skin and Pagets carcinoma, with eczema of the nipple. In these carcinomas the clinical signs are often more evident than the radiological ones. NODULE / MASS IN THE MALIGNANT CATEGORY 5.1. Nodule or mass, with spiculated contours, often associated with microcalcifications with signs of malignancy with or without alterations in the skin, nipple or pectoral muscle, associated on occasions with axillary adenopathies. Many breast carcinomas, especially ones with ductal origins, are seen in radiology as nodules, normally of high density, with spiculated contours (1). The spiculations can be short or long, of different thickness, and reflect zones of fibrosis in relation with the desmoplastic reaction which provoke some tumours on the healthy surrounding tissue. In these we can find microscopically tumoral cells (2). These spiculations can even contact the skin or the pectoral muscle, making these thicken and retract (Fg.1 and 2). When the mass or stellate nodule is in a retroareolar location, it may condition a retraction of the nipple (Fig.3). There are occasionally associated microcalcifications with malignant radiological characteristics, the diagnosis of malignancy being practically certain in these cases (Fig. 4 and 5).
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STRUCTURAL ALTERATION IN THE MALIGNANT CATEGORY 5.2. Tumoral structural alteration, associated with tumoral asymmetrical density, malignant microcalcifications and occasionally alterations of the skin or nipple. The pattern for the architecture of normal glandular tissue assumes a morphology which converges from the periphery towards the nipple, following the direction of the galactophorous ducts. When this arrangement is altered, and the mammography reveals part of the glandular tissue aiming at a point other than the nipple, this can be described as a distortion of the glandular architecture. On occasions, it is the fibres which are altered, increasing in number, in size and also in direction, and seen as an image converging on a point, which is known as the stellate image. This type of radiological presentation can also be caused by benign lesions such as fatty necrosis, postoperative scarring and other pathologies such as sclerosing adenosis or radial scars. Every alteration in structure have to be considered probably malignant, unless the case history record points one towards a scar caused by prior surgery or fatty necrosis through traumatism or reductive surgery. The readings which put a lesion into the malignant category are the association of a structural alteration, with no prior traumatic case history, with radiologically malignant microcalcifications (Fig. 6), or with a thickening and retraction of the skin or nipple, as well as the presence of axillary adenopathies. CALCIFICATIONS IN THE MALIGNANT CATEGORY 5.3. Widespread microcalcifications with signs of malignancy. Diverse shapes, linear, vermiform or branched with irregular contours, along with other granular microcalcifications of different sizes and variable density. ASYMMETRIES IN THE MALIGNANT CATEGORY 5.4. Tumoral asymmetry, associated with structural alteration, microcalcifications, with signs of malignancy, thickening and retraction of the skin or nipple, and occasionally axillary adenopathies. This form of asymmetry, which should be studied comparatively with the contralateral breast, has poorly defined limits and is often associated with the alteration of the structure, this being more evident than density asymmetry in dense breasts, while in fatty breasts density asymmetry is more evident. On occasions palpation is positive. This form of presentation of breast cancer is less frequent than the ones previously reviewed. The radiological image will reveal a zone of greater density in comparison with the same zone of the contralateral breast, which tends to be displayed in the two routine projections (CC and MLO), though occasionally it is only visible in one of these. The densest zone is in the centre of the lesion, gradually attenuating towards the periphery. We will consider a zone of asymmetrical malignant density, when this is palpable and is associated with alteration of the glandular architecture, microcalcifications with signs of malignancy, or with thickening and retraction of the skin. (Fig.7 a and b). ALTERATIONS OF THE SKIN AND NIPPLE IN THE MALIGNANT CATEGORY 5.5. Alterations of the skin and nipple. Includes clinical-radiological diagnosis items: 5.5.1. Inflammatory carcinoma: Inflammatory breast cancer is an infrequent variety of locally advanced breast cancer (3). Its diagnosis is made by jointly valuing the clinical, radiological and histological findings, the first being of special relevancy, both in this type of tumour and in Pagets disease. Clinically this tends to be seen as an increase in size of the breast with a change in the skin colouring, which may vary from a reddish or violet shade with ecchymotic appearance, in at least one third of the breast (4-6), or appear as peau dorange, thus known through the appearance conditioning an increase in the depressions surrounding the hair follicles as a result of the presence of oedema of the skin (9) (Color photo 1). The breast is sensitive and reacts painfully when examined, it being possible to palpate a real mass or a zone induration. There may also be an increase in temperature and retraction of the nipple. It is common to find homolateral palpable axillar adenopathies
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C ATEGORY 5. M ALIGNANT

(5, 6, 8). In very advanced stages there is cutaneous ulceration. This form of clinical presentation of breast cancer can be brought about by any of the histological types which cause mammary carcinoma, but to make a diagnosis of inflammatory carcinoma it is essential that the dermic lymphatics should display tumoral invasion in the histological study (3). From the radiological standpoint the collection of mammographic findings of tumoral density or mass associated with inflammatory changes such as thickening of the skin (Fig. 8), overall increase in the density and diffuse trabecular thickening should make one think of inflammatory carcinoma (Fig. 9 a and b), (8). When we only find inflammatory signs this will probably be some other pathology such as: mastitis, mammary abscess, breast subject to conservation treatment with recent radiation or surgery, lymphomas, pseudolymphomas, or metastatic disease which may cause primary affection of the breast through direct infiltration or secondary affection through lymphatic obstruction through malignant nodes axillary pathology (4). 5.5.2. Pagets disease This is a special variant of ductal carcinoma, in which the tumoral cells extend distally through the galactophorous duct to the epithelial surface of the nipple (9). The age at which this occurs is over that of other types of breast cancer, its maximum incidence being at over seventy-six years of age. Patients tend to have eczematic changes in the nipple which may be impossible to distinguish from non-tumoral etiology nipple eczema. (Color photo 2) (9-11). Radiologically the mammography can be normal, or reveal a thickening of the nipple-areola complex, a dilated duct, calcifications of malignant type, as mass in retroareolar location (Fig. 10) or in any situation of the breast. Occasionally there may be telorrhagia, with this occurring when the breast is compressed to perform a mammography (9, 12). It should be stressed that the clinical appearance of the nipple has nothing to do with the radiological presence or absence of underlying carcinoma and thus a negative mammography in the presence of suspicious clinical alterations in the nipple does not exclude the diagnosis of Pagets disease (9, 10). COMBINED/ MULTIPLE 5.6. All the lesions included in the Malignant Category are combinations of probably malignant lesions, with or without alterations of the skin, nipple, retraction of the pectoral muscle and occasionally with axillary adenopathies. There are nevertheless combinations of small-sized probably malignant lesions, which are known as minimum signs, that may be associated and difficult to make out. In these cases, in spite of the combination of lesions, these should continue to be included in the probably malignant category. 5.6. The lesions included in the Malignant Category can be multiple and be located in one or both breasts. OTHERS 5.7. Includes any finding in the normal, benign or probably benign category, which is found simultaneously with the findings of the Malignant Category. CONDUCT GENERATED BY THE MALIGNANT CATEGORY In every case it is compulsory to obtain a cytological/histological analysis of the lesion, either through core biopsy or surgery according to the protocols of the multidisciplinary breast committees of the reference hospitals, to decide on the appropriate therapeutic strategy (chemotherapy, radiotherapy and surgery). In Pagets disease, a smear of the nipple may be useful, and in inflammatory carcinoma, biopsy of the skin to verify the neoplastic infiltration. N.B. All the cases described in the figures in this chapter are histologically verified carcinomas.

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Bibliography
1. Tabr L. Dean PB. Stellate/Spiculated lesions. In: Teaching Atlas of Mammographie. (3rd edi.). New York: Thieme 2001; 93-96. 2. Kopans DB. Apariencia mamografica del cncer de mama. In: La mama en imagen. Madrid: Marban 1999; 377-380. 3. Dershaw DD, Moore MP, Liberman L, Deutch BM. Inflammatory breast carcinoma: mammographic findings. Radiology 1994 Mar. 190: 831-34. 4. Jaiyesimi IA, Buzdar AU, Hortobagyi G. Inflammatory breast cancer: a review. J. Clin. Oncol. 1992; 10: 6, 1014-24. 5. Berger SM. Inflammatory carcinoma of the breast. AJR 1962; 88: 1109-16. 6. Tardivon AA; Viala J; Corvellec A; Guinebretiere JM; Vanel D. Mammographic patterns of inflammatory breast carcinoma: a retrospective study of 92 cases. Eur.J.Radiol. 1997; 24: 2, 124-30. 7. Kopans DB. Carcinoma inflamatorio de mama. In: La mama en imagen. Madrid: Marban 1999; 590591. 8. Shaw de Paredes E. Atlas de Mamografia. Madrid, Ed Marban 1994; 451-52.457. 9. Sawyer RH; Asbury DL: Mammographic appearances in Pagets disease of the breast. Clin. Radiol 1994; 49: 3, 185-88. 10. Ikeda DM; Helvie MA; Frank TS; Chapel KL; Andersson IT. Pagets disease of the nipple: radiologicpathologic correlation. Radiology 1993; 189: 1, 89-94. 11. Jamali FR; Ricci A Jr.; Deckers PJ. Pagets disease of the nipple-areola complex. Surg. Clin. North.Am. 1996; 76: 2, 365-81. 12. Dixon AR; Galea MH; Ellis IO; Elston CW; Blamey RW. Pagets disease of the nipple. Br. J. Surg., 1991; 78: 6, 722-3.

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CHAPTER VII MISCELLANEOUS


T. Garca Redn, M. Redondo Ibez, R. Piqueras Olmeda and J. Nez de Bobadilla.
Introduction This chapter includes the description of artefacts, some relatively common, such as the ones caused by creams or deodorants which may lead to errors in the mammographic reading. It also describes the foreign bodies which may be found after earlier surgery or arise accidentally. The increasing use of plastic surgery and mammary reconstruction surgery means we have to know some data about specific mammographic findings connected with materials and techniques used. Lastly, this chapter includes the description of some seldom found malignant tumours, both primary and metastatic. Artefacts and superposition Certain substances applied on the skin may be radio-opaque and suggest microcalcifications, such as creams or ointments which include zinc oxide (1, 2) in their composition. Deodorants and talcum powders have similar characteristics and may also appear, mimicking calcifications. Artefacts produced by soaps which contain additives such as barium sulphate, sodium and potassium hydroxide have been described, as well as ones occurring simply through washing with very hard waters rich in calcium salts (3). These appear as very fine granular densities on the surface of the breasts or in axillary or inframammary folds (Fig. 1, page 143). If there is any clear suspicion the zone should be washed thoroughly and the mammographs repeated. The gold salts administered via intramuscular injection to rheumatoid arthritis develop gold deposits in intramammary and axillary lymph nodes which mimic microcalcifications (1). Tattoo marks on the skin may also appear to be microcalcifications (3). Other artefacts such as fingerprints on the films, dust on the screens or hair superposed on the mammary parenchyma are easily recognised (4). Topically administered antimitotic (5-fluoracil) abrasive substances may provoke cutaneous ulcers, which might be confused with ulcerations inside a carcinoma (we include a case of self-lesions with Efudix) (Photo 1, page 143). Foreign bodies Foreign bodies such as needles (Fig. 2, page 144), pieces of glass, pencil points or projectils (Fig. 3, page 144) and others (2) are occasionally found, whether the patients are aware of these or not, but nevertheless asymptomatic. Sutures, which may calcify after surgical biopsies, tumorectomies, reductive mammoplasties, will be seen as calcifications, linear or in knot form (Fig. 4, page 145), (5). The location of the surgical scar must be correlated with the calcification zone. Some of the complications reported in the use of hook wires for biopsies of non-palpable lesions are the breakage and loss of fragments inside the breast (Fig. 5, page 145), meaning that if the
43

fragment is not recovered or identified after surgery, a mammography must be carried out to look for this as soon as possible and verify the stability of the fragment in series of mammographies after three and six months. This approach is logical since intramammary fragments are usually asymptomatic and their location will require placing a second hook wire and further surgery. No complications with fragments of hook wires have been described unless these fragments remain in the pectoral muscle (6). As a preventive measure the use of hook wires close to the pectoral muscle should be avoided, the guide should be long enough not to remain submerged in the breast after initial decompression and the outer end has to be securely fixed. Appropriate surgical technique must be used, avoiding cutting the hook wire (leaving the needle along with the hook wire already anchored may be of use) (7). The radiologist must always check for the presence of hook wire in the surgical specimen (6). Cases have also been reported of metal particles similar to those of hook wires located after carrying out biopsies with hook wires, but their ethiology is uncertain (8). Pacemakers in subpectoral locations may be superimposed over the pectoral muscle in the MLO projection (Fig. 6, page 146). In some patients microcalcifications have been seen in the cavity left by the pacemaker after removing this. The Dacron sheath of Hickman catheters (used for administering antibiotics or chemotherapy by central catheterisation) is used for anchoring the catheter to the subcutaneous tissue. This cuff may be left after removing the catheter, proving to be palpable and showing up in the mammography (4) (Fig. 7, page 146). In the event of foreign bodies suspected of being gauze, drains, or fragments of needles being seen (Fig. 2, page 144), the surgical case history must be investigated (5). Mammary prostheses and reduction surgery. An increasingly large number of women are resorting to prostheses, both for postmastectomy reconstruction, and for purely aesthetic purposes. Certain types of prosthesis may represent an obstacle for early breast cancer diagnosis, as their opacity may conceal lesions. Until 1950 the injection of paraffin was used and in 1959 polyvinyl alcohol sponges started to be implanted. From 1950 to 1960 the technique used was silicone injection (Fig. 8, page 147). From 1962 silicone prostheses were implanted. In 1976, the FDA established the need for control, and in 1991 it determined the hazards and relation with immune and collagen diseases. In 1992 the FDA accepted prostheses under strict clinical control. There are the following kinds of prostheses: CASING Silicone Polyurethane and silicone Silicone Silicone CONTENT Silicone Silicone (this prosthesis is currently not used due to the polyurethane) Physiological serum Combinations of silicone serum or inverse. This prosthesis generally has two bags: silicone gel outside and physiological serum inside, with a small valve used for filling the prosthesis with serum. This valve showed up in the mammography in some cases. Soya oil (Triglyceride). This prosthesis was withdrawn in 1999 by the European Union Health Vigilance System, with the explantation of these being ordered through problems connected with the degradation of the oils. Hydrogel Silicone with cohesive gel and items.

Silicone

Silicone Silicone

The prostheses which contain silicone are the most opaque; the ones with serum have an intermediate opacity and the ones with triglycerides are the most radiotransparent, (reference has already been made to the order for withdrawing these.)
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Prostheses generally have a variable and not very long lifetime, from 5 to 15 years approximately, which is why their control is recommended. The average life of prostheses is gradually lengthening as the technology and the characteristics of implants progress. Prostheses are classified, depending on their location as: - Submuscular: fitted under the pectoral muscle (Fig. 9 a and b, pages 147 and 148). - Subglandular: fitted under the gland and in front of the pectoral muscle, also known as intramammary prostheses (Fig. 10 a and b, pages 148 and 149). - Subcutaneous: fitted under the skin. The problems that may be found in breasts containing prostheses are: - Capsular rupture with loss of the content and volume (Fig. 11, page 149). - Rupture of the prosthesis, without migration of the cohesive gel. - Exudation of the content with an intact capsule. - Contraction of the fibrous capsule. - Immune affections and collagen diseases (systemic lupus erythematous, schlerodermia, Sjegrens syndrome, rheumatoid arthritis, inflammatory polyarthritis, polymyositis, dermatomyositis...) though these are not very common. - The risk of induction of breast cancer has been mentioned in some publications without any thorough studies having been made on this matter. - Difficulty in early diagnosis. Breast prostheses interfere in the early diagnosis of breast cancer through their opacity, which makes it difficult to display the full mammary parenchyma. One must take into account that submuscular-located prostheses and the most radiotransparent sorts are the ones which poses fewest problems for mammographic diagnosis, which is why these are the most recommendable ones from the radiological standpoint. The prostheses which mean a greatest hindrance for reading are the silicone subglandular and subcutaneous implants. The projections recommended in breasts with prostheses are: - Medio-lateral-oblique with free technique (without using the automatic exposure). - Craniocaudal, drawing the prosthesis back (Eklunds manoeuvre) (Figs. 9 b and 10 b, pages 148 and 149). If the prosthesis constitutes a total impediment for mammographic reading, and if there is grounded clinical suspicion, significant family risk or the patient suffers from cancerophobia, other diagnostic imaging methods can be used such as Magnetic Resonance with contrast. Reductive mammary surgery can be recommendable in problems connected with large mammary volume, such as: posture problems, cervical and dorsal vertebral pathology, painful processes of the chest wall and breasts, exaggerated respiratory effort, which may induce pulmonary involvement, intertrigo in inframammary creases, mammary asymmetry, psychological problems etc.. Several surgical techniques have been described, but these basically consist in drying out mammary tissue and skin, and displacing the aureole-nipple complex. An incision can be made in the form of an inverted T with a vertical part from the nipple downwards and horizontal line which goes right along the inframammary crease. An L from the aureole to the submammary sulcus and outer lateral or a vertical I incision from the aureole to the sulcus. In the mammography, an MLO projection will reveal downward displacement of the mammary tissue with a ring-shaped or twisted formation, as well as tilting or elevation of the nipple, and dermal thickening in the vertical incision between the nipple and the inframammary crease. In CC and MLO projection dense bands resulting from fibrosis can be seen in retroareolar projection, as well as redistribution and atypical or focal asymmetries of the mammary tissue. There may also be thickening of the skin coinciding with the incision lines previosly described (Fig. 12 a and b, page 150), (9). In the case of gigantomasty, aesthetic amputation of a large amount of mammary tissue is made with free grafting of aureole-nipple, with the mammographic reading proving simpler through there being less structural alteration and reduced displacement. Seldom-found tumours This category includes sarcomas, lymphomas and metastases.

45

Sarcomas These are malignant tumours originating in the mammary stroma. These are rare, constituting under 1% of all the malignant tumours of the breast. They appear from 45 to 55 years of age. They include highly differentiated forms such as fibro, angio and liposarcomas, or sarcomas of highly immature cells in which cartilaginous or osseous tissue can be found (Fig. 13, page 151). These are clinically seen as large masses with fast growth in size of the breast, almost mimicking inflammatory processes, and with distortion of the mammary contour (10). These are mobile and non-adhered masses. Mammographically they look like large well-defined and dense rounded or lobulated nodules (11). They metastasise through the blood, generally to the lungs. Angiosarcoma is differentiated through its different clinical and radiological characteristics. This is a very rare malignant lesion (0.04% of all malignant breast tumours). It has a very bad prognosis. It may appear at any age though it is more commonly found in young women. It may also appear after radiotherapy. Bilateral disease tends to be associated with pregnancy. The clinical signs are unspecific, such as a painless mass or diffuse mammary increase. The most specific sign, which is the violet red or blue colouring of the adjacent skin, only occurs in 17-35% of cases. In mammographies the findings are variable, and it may be seen as a mass with poorly defined or lobulated contours, and microcalcifications and spiculations are not associated with this. The 35% may have a negative mammography. Because of its great vascularisation there may be a haemorrhage after biopsy. They tend to involve fast metastatic dissemination (12). Phyllodes Tumour A potentially malignant tumour which is differentiated from sarcomas through containing epithelial tissue structures. It represents under 1% of mammary tumours. The great proliferation of its epithelial elements and of the stroma produces elongation and distortion of the ducts, which gives rise to clefts or cystic cracks inside the tumour. These appear from 30 to 50 years of age. Most of these lesions are benign, but differentiation between benignity and malignancy is only possible by means of a histological study, by valuing mytotic activity, cellular atypia, cellularity, growth of the stroma and characteristics of the edges (2, 13). These tumours can be locally invasive and recur if not properly extirpated, the recurrences sometimes being more aggressive than the original tumour. If this metastasises the process is haematogenic and not by the lymphatic channel. The metastasis of the phyllodes tumour acts in the same way as sarcomas. This is seen as a quickly growing mass, with smooth or lobulated edges and with certain mobility. In mammography they are indistinguishable from other well-defined mammary lesions, do not have spiculations nor microcalcifications, and are distinguished by their large size (Fig. 14, page 151). With ultrasound it is identical to fibroadenomas, well defined. Sometimes cystic zones can be seen. The most advisable treatment is extensive excision and a mastectomy must be performed if there is any recurrence. Lymphoma Primary breast lymphoma is very rare, 0.1-0.5%. Secondary affectation is more common and the distinction between these is based on the fact that for diagnosis the primary form requires normal mammary tissue around a focus of lymphoma in a patient with no other evidence of systemic affectation through this process (11). Under examination this may be found as a palpable not painful mass. Mammographic findings of the lymphoma are not specific and furthermore there is no radiological sign which distinguishes the primary lymphoma from the secondary one (11). The most common finding is the presence of a nodule or mass and, less frequently, several masses or nodules, not calcified, with a circumscribed, oval or lobulated contour, or even poorly defined, and almost never spiculated (14) (Fig. 15 a, b and c, pages 152 and 153). Less frequently, these have been described as density asymmetries in combination with thickening of the skin. If there are also large axillary or thoracic adenopathies one must always discard the
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possibility of the generalised lymphoma (2), and there may be lymphoedema and an interstitial pattern with thickening of the skin through obstruction of the lymphatic drainage (11). This is generally unilateral, though it can be bilateral. With ultrasound it seen as a highly vascularised unspecific hypoechoic mass (15). Metastasis In mammography most of the metastatic lesions mimic benign nodes like cysts or fibroadenomas. Metastases in breasts are single in 85% of cases, unilateral in 75%, and with a predilection for UOQ. Excluding metastases of contralateral breast carcinomas and of the lymphoma group, most of the metastases stem from melanoma, bronchial carcinoma, carcinoma of the ovary, kidney and soft tissue sarcomas. (16,17). These appear in mammography as one or more well-defined, rounded (Fig. 16, page 153), or lobulated nodes with fast growth between sequential mammographies. These must also be suspected when one finds a well-defined nodule, localised in the subcutaneous fat and not in the mammary gland itself, or when its location is unusual or eccentric. Metastatic lesions are not usually accompanied by changes in the skin or spicula through the lack of a desmoplastic reaction (18). Very seldom these go with microcalcifications (such as with metastases or carcinoma of the ovary, or of medullary thyroid carcinoma) (17). Cytology is useful for differentiating metastases from primitive breast carcinoma. All the mammary tumoral lesions described in this chapter require a definitive histological diagnosis.

Bibliography
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Shaw de Paredes E. Atlas de Mamografia. Madrid: Ed. Marban 1994. Kopans DB. Alteraciones focales en la mamografa. In: La mama en imagen. Madrid: Ed. Marban 1994. Thomas DR, Fisher MS, Caroline DF. Case report: Soap, another artefact that can mimic intramammary calcifications. Clinical Radiology 1995; 50: 64-66. Cardenosa G, Ecklund GW. Breast calcifications. In: Taveras JM y Ferrucci JT eds. Radiology Diagnosis Imaging Intervention. Philadelphia: J.B. Lippincott Company 1994. Iribar M, Vilarrasa A. Alteraciones Radiolgicas de la mama tratada. In: Monografas de Diagnostico por Imagen 1992; 1: 101-125. Montrey JS, Levy JA, Brenner RJ. Wire fragments after needle localization. AJR 1996; 167: 12671269. Homer MJ. Needle localization: Pitfalls. In: Mammographic interpretation. A Practical approach. New York. Mc Graw-Hill Inc. 1997. Korbin CD, Denison CM, Lester S. Metallic particles on mammography after wire localization. AJR 1997; 169: 1637-1639. Cardenosa G, Eklund GW. Imaging the altered breast. In: Taveras JM y Ferrucci JT eds. Radiology Diagnosis Imaging Intervention. Philadelphia: J.B.Lippincott Company 1994. Cotran RS, Kumar V, Robbins SL. The Breast in: Robbinss Pathologic Basis of Disease. Philadelphia. W.B.Saunders Company. 1989; 1181-1201. DOrsi CJ, Feldhaus L, Sonnenfeld M. Unusual lesions of the breast. The Radiol. Clin. of North Am. 1983; 67-69. Marchant LK, Orel SG, Perez-Jaffe LA, Reynolds C, Schnall MD. Bilateral angiosarcoma of the breast on MR Imaging. AJR 1997; 169: 1009-1010. Liberman L, Bonaccio E, Hamele-Berna D, Abramson AF, Cohen MA, Dershawd DD. Benign and malignant phyllodes tumors: Mammographic and sonographic findings. Radiology 1996; 198: 121-124. Pameijer FA, Beijerinck D, Hoogenboom HHVM, Deuremberg JJM, Nortier JWR. Non Hodgkins Lymphoma of the breast causing miliary densities on mammography. AJR 1995; 164: 609-610. Kizitelpe TT. Breast metastasis from non Hodgkins lymphoma: evaluation with color Doppler sonography (letter) AJR 1996; 167: 1595-1596. Hiorns MP, Murfitt J. Granulocytic Sarcoma (Chloroma) of the breast: sonographic findings. AJR 1997; 169: 1639-1640.
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17. Soo MS, Williford ME, Elenberger CD. Medullary thyroid carcinoma metastatic to the breast: mammographic appearance. AJR 1995; 165: 65-66. 18. Belton AL, Stull MA, Grant T, Shepard MH. Mammographic and sonographic findings in metastatic transitional cell carcinoma of the breast. AJR 1997; 168: 511-512.

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APPENDIX I

DIAGNOSTIC PROTOCOL
MAMMOGRAPHY: MAMMOGRAPHIC CATEGORIES AND IMAGE DESCRIPTIONS Mammography is the imaging technique normally used to detect a clinically occult breast carcinoma. Roughly 80-85% of all breast cancers can only be detected by mammography. Physical examination can detect 18-25% of breast cancers. A combination of physical examination and mammography can improve detection up to 90-95%. The remaining 5% of cases not detected are made up of diffuse, infiltrating lesions which do not form a mass. Physical examination and mammography must be correlated since a carcinoma can be concealed by a dense glandular tissue in the mammography. A palpable mass in a patient with a negative mammography must therefore be investigated by ultrasound and a cytological or histological study. The pattern for action in our screening programme is as follows: A bilateral mammography is made in a dual projection (craniocaudal and medio-lateral-oblique) in the first round and single projection (medio-lateral-oblique) in successive rounds. A double reading is performed: a first reading by the physician or radiologist at the facility and a second independent reading by the reference radiologist. Both are blind, and in the event of any disagreement a consensus between readers must be established. The results of the mammography reading are classified in the following categories: 1. - NORMAL: 1.1. - NORMAL FATTY. 1.2. - NORMAL DENSE. 2. - BENIGN. 3. - PROBABLY BENIGN. 4. - PROBABLY MALIGNANT. 5. - MALIGNANT. CATEGORIES: Categories constitute each of the concepts or hierarchies which are established from normality to breast cancer. At present we have discarded Category 1 NOT PERFORMED, through not meeting the definition of mammographic category. BIRADS Category 0 requires further assessment, and is not used by our readers as an initial category but is instead a procedure to be followed proposed during consensus. In the remaining Categories we have adopted the BIRADS numbering, maintaining the terms used in our program and changing the numbering, in order to make the numbers in both systems coincide. Category 1, NEGATIVE, is known as NORMAL. We prefer to use the term normal when we refer to a mammography reading which does not show any signs of pathology. We admit that a normal mammography does not mean a normal breast or the absence of cancer and only means a lack of signs indicating pathology, and both concepts are thus equivalent.
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Only this category adds the constitution of the breast. The BIRADS system puts forward four types of breast and justifies this system based on the sensitivity of the mammography in each kind of breast, but without quantifying this sensitivity. By simplifying this application two types of breast will be allowed, the highly sensitive sort, which we call NORMAL FATTY, and the type that can conceal some type of cancer behind the fibroglandular tissue, which is known as NORMAL DENSE. Category 2 BENIGN FINDING in the BIRADS is known as BENIGN and in both systems it includes the same lesions, with the exception of the intramammary lymph node of normal morphology, size and density, which we include as an anatomical variant in the Normal Category. The lesions included in this category are detailed in the corresponding chapters as well as the procedure to follow. The classification section of this chapter includes a list of these lesions. Category 3 The BIRADS PROBABLY BENIGN FINDING is called PROBABLY BENIGN and includes the same lesions. The lesions included in this category are detailed in the corresponding chapters as well as the procedure to follow. The classification section of this chapter includes a list of these lesions. Category 4 The BIRADS SUSPICIOUS ANOMALY is called PROBABLY MALIGNANT and includes the same lesions. The lesions included in this category are detailed in the corresponding chapters as well as the procedure to follow. The classification section of this chapter includes a list of these lesions. Category 5 HIGHLY SUGGESTIVE OF MALIGNANCY in the BIRADS system is known as MALIGNANT and includes the same lesions. The lesions included in this category are detailed in the corresponding chapters as well as the procedure to follow. The classification section of this chapter includes a list of these lesions. LOCATION In the Checklist used by the first and second mammography reader, we have implemented a scheme for locating the lesions in the breast. The scheme represents the two radiographic projections, CC and MLO, and indicates the laterality, right or left-hand side and also the upper and lower references for MLO projections and internal and external references for CC projections. One should remember that the lesion marked on the radiographic projection scheme may require translation to the anatomical situation. DESCRIPTION: The description of the mammographic reading involves some differences and finer distinctions now explained: Masses. We add the nodule. NODULE/MASS. These are lesions occupying space which can be seen in two projections. The nodule is concrete, small in size and can be individually distinguished from everything surrounding it. The mass is large in size. The size limit for considering a lesion as being a nodule or mass can arbitrarily be established as 2 cm (Maximum diameter of the T-1). We accept the BIRADS definition referring to three-dimensionality in two projections and also the study system for masses proposed for classification in the final categories. We exclude the term density for not meeting the definition of mass through being two-dimensional and through having located this in the asymmetrical density section as ASYMMETRY. We include the intramammary lymph node through complying with the definition of node and when its morphology and size are normal we classify this in the normal category, through considering this to be a normal anatomical variant. Lymph nodes whose size, density, morphology or surroundings suggest adenopathies are included in the probably malignant and malignant categories.
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We also include the skin lesions which produce a nodular image in the mammography, such as the naevus and warts, not considering these as being breast pathologies. Distortion of architecture. We use the same definition and classification proposed in the BIRADS. STRUCTURAL ALTERATION. Alteration of the structure or harmonic distribution of the parts forming a body. This mainly refers to fibrillar elements. One form of structural alteration is the star. This name is used through its similarity with a starshape. It consists in a radial image which converges on some point other than the nipple. We include trabecular thickening, which in the BIRADS system is classified as an associated finding. Calcifications. We use a definition and classification similar to that of BIRADS: CALCIFICATIONS. A transformation undergone by tissue through calcium salts being deposited on these. These deposits are visible and identifiable in mammographies, even being of minimum size, measurable in micras. We consider some calcifications such as vascular, dermic and cicatricial as being normal. ASYMMETRY: Asymmetry is the lack of symmetry. We consider symmetry to be a harmony of position between similar parts or points, in respect of each other and with regard to a particular point, line or plane. This basically refers to fibroglandular tissue. By following this concept we value the symmetry of radiological density by placing the projections of the breasts so that one is the mirror image of the other, and we analyse the distribution of densities in each projection comparing both breasts. Special cases. Of the four cases indicated in the BIRADS as special cases, one of these Intramammary lymph node - has been moved to the NODULE / MASS section, through considering that it complies with the definition of this. The other three: Tubular density or isolated dilated duct, Asymmetric mammary tissue and Focal asymmetric density, have in common the fact that these are radiological densities and are also symmetrical. We think that these three concepts can be included in a common section which we call ASYMMETRICAL DENSITY, or simply ASYMMETRY, which from a descriptive standpoint is more specific than the special cases used in the BIRADS system, which means the type of case being referred to has to be specified. Of the three cases, density in fibroglandular tissue will be considered as being normal or benign, tubular density as probably benign and focal density as suggestive of malignancy. Associated findings. These are considered to be an extremely heterogeneous series of signs which can either be found isolated or in combination with other signs. Their heterogeneity makes it difficult to classify them in groups, which is why we opted for seeking a solution to allow them to be collected as information, in the same way as the previous section. To do this we will divide this group into several groups: ALTERATIONS OF THE SKIN/NIPPLE. Altering means changing the essence or form of something. We analyse above all the change in the thickness of the skin and the nipple, comparatively studied, as well as any retraction, sinking or alteration in its surroundings. It groups the descriptions of the BIRADS and can be found as a single or associated lesion. COMBINED/MULTIPLE: This indicates that the lesions described above are associated through constituting the lesion which gives rise to the main category. It excludes adenopathy, which should be included in the nodule /mass section. It includes the distortion of architecture, calcifications, alterations of the skin and nipple and multiple instances of the lesions described in the same category. It should not be used to relate different categories. OTHERS: This refers to lesions or images of a lower category whose presence the reader wishes to inform of or record, although the type of image is not described. MISCELLANEOUS: This includes artefacts, foreign bodies and implants or infrequent tumours of known diagnosis.
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For the classification of mammographic studies in categories we use a reading system based on the description of images which includes the following terms that have been defined and endorsed: 1. 2. 3. 4. 5. 6. 7. 8. NODULE / MASS STRUCTURAL ALTERATION CALCIFICATION ASYMMETRY ALTERATIONS OF THE SKIN / NIPPLE COMBINED / MULTIPLE OTHERS MISCELLANEOUS

REMARKS The reader wishes to express, in the form of free text, any observations which are not mentioned in the reading system and which may refer to technical data or notes for specifying some detail of the reading. PROCEDURE TO BE IMPLEMENTED Just as these categories are equivalent to the ones used by the BIRADS system, so is the approach or PROCEDURE TO BE IMPLEMENTED. The approach or procedure to be implemented is determined after performing the double reading and consensus at our facilities. The physical examination and further projections are made at the screening facilities, by the physician or radiologist of the facility, though there is no possibility of performing ultrasounds as this technique is not available at the facilities. The procedure to be implemented considers the following cases: 1) NORMAL FOLLOW-UP. In two years in our screening programme. Made with women from the normal and benign categories. 2) SHORT-TERM FOLLOW-UP. In our programme, since the time elapsing between checkups is two years, the short-term follow-up is given at six and twelve months. This is for women with particular lesions in the probably benign category. 3) SENDING ON TO HOSPITAL. This is applied to women for whom the study must be completed for obtaining the final diagnosis and who require ultrasound or some type of intervention test for cytological or histological diagnosis. This is implemented with women with certain probably benign lesions, and women who were included in the probably malignant and malignant categories. ULTRASOUND Ultrasound is used for differentiating the solid or liquid nature of a mammary nodule. It does not distinguish benignity from malignancy and neither does it detect microcalcifications, meaning that ultrasound is no use for carrying out screening in a programme for prevention of breast cancer. Ultrasound will be used as follows in the Programme: - For differentiating the solid or cystic nature of a nodule. - For assessing a palpable mass in a dense breast or within an asymmetric density. - For valuing masses or nodules whose location means that they might not have been included in the mammography. - Ultrasound is a useful method in interventionist procedures, for guiding needles in FNAB and also in obtaining cores with core needles. It can watch over total evacuation of a cyst, and is useful for placing signals with hookwires in lesions which are easily visible in ultrasound. When there is a palpable mass which cannot be shown to be cystic in the ultrasound, this must be considered to be solid, proceeding to a cytological or histological study of this.
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CLASSIFICATIONS CATEGORIES 1. Normal 1.1. Normal fatty 1.2. Normal dense 2. Benign 3. Probably benign 4. Probably malignant 5. Malignant

TYPE OF MAMMOGRAPHIC IMAGE Description of the lesion 1. NORMAL 1.1. Nodules 1.1.1. Lymph node. 1.1.2. Lesions in the skin (warts, sebaceous cyst...). 1.2. Structural alteration 1.2.1. Pseudostar produced by superimposing the normal structures of the breast. 1.3. Calcifications 1.3.1. Vascular calcification. 1.3.2. Microcystic calcifications. 1.3.3. Dermic calcifications. 1.3.4. Cicatricial calcifications. 1.4. Asymmetries 1.4.1. Vascular. 1.4.2. Of volume. 1.4.3. Of fibroglandular tissue (retroareolar or in UOQ, with fat, not volumetric, visible in a single projection). 1.5. Alterations of the skin/nipple 1.5.1. Scar. 2. BENIGN 2.1. Nodule/Mass 2.1.1. Nodules of water density 2.1.1.1. Sharp nodule of 5-10 mm in size, well-defined contour and low density, transparent. 2.1.1.2. Nodules considered benign after ultrasound, follow-up, review of previous studies or cytological or histological studies. 2.1.2. Nodules with fatty density 2.1.2.1. Hamartoma 2.1.2.2. Lipoma 2.1.2.3. Galactocele 2.1.2.4. Oily cyst 2.2. Structural alteration 2.2.1. Structural alteration through traumatism 2.2.2. Structural alteration through surgery 2.2.3. Structural alteration through infection 2.3. Calcifications 2.3.1. Calcification of fibroadenoma 2.3.2. Macrocystic liponecrosis
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Granulomas of foreign bodies Ductal or periductal with sharp contour Calcium milk in cyst Disperse microcalcifications of benign morphology, homogeneous, unilateral or bilateral, with a tendency to symmetrical distribution, and which do not form groups or pseudogroups. 2.4. Asymmetries 2.4.1. Asymmetries of fibroglandular tissue secondary to traumatism, infection or surgery. 2.4.2. Asymmetries of fibroglandular tissue considered as being benign after ultrasound, followup, review of previous studies or cytological or histological study. 2.5. Alterations of the skin/nipple 2.5.1. Localised thickening of the skin. 2.5.1.1. Infection 2.5.1.2. Traumatism 2.5.1.3. Surgery 2.5.2. Diffuse thickening of the skin, associated with generalised oedema through mastitis, heart or kidney disease. 2.6. Combined, multiple: Includes all the possible combinations of benign findings, or the unilateral or bilateral simultaneous presentation of benign, isolated or combined findings. A frequent finding of benign combined lesion is the nodule with signs of benignity and calcifications whose morphology means these are typical of fibrodenoma. 2.7. Others: Includes any finding in the normal category, which is found simultaneously with the benign findings.

2.3.3. 2.3.4. 2.3.5. 2.3.6.

3. PROBABLY BENIGN: 3.1. Nodule/mass: Sharp nodule of smooth contour, well-defined, round, elliptical or discretely lobulated without calcification. 3.2. Calcifications: Microcalcifications, grouped, round, oval or spherical, homogeneous with a sharp contour, small, amorphous, in corn-flakes or blurred. 3.3. Asymmetry: of fibroglandular tissue, with volume effect, visible in two projections, located in areas other than the areolar or upper-outer regions. 3.3.1. Asymmetry of the parenchyma. 3.3.2. Ductal asymmetry. 3.4. Combined/multiple: Includes all the possible combinations of probably benign findings, or the simultaneous unilateral or bilateral probably benign, isolated or combined findings. 3.5. Others: Includes any finding in the normal or benign category found simultaneously with probably benign findings. (1)

4. PROBABLY MALIGNANT: 4.1. Nodules: with poorly defined contour, spiculated, irregular, polylobulated or microlobulated or with an extension in comet-tail form. 4.2. Structural alteration 4.2.1. Stars. 4.2.2. Structural alteration of the architecture of the breast without associated mass. 4.3. Calcifications: Microcalcifications with characteristics of malignancy, either grouped or in regional or segmentary distribution, heterogeneous in shape, size and density, intraductal, vermiform, granular, with irregular poorly defined contours. 4.4. Asymmetry: Tumoral, with mass effect, associated with structural alteration or with malignant type microcalcifications.
54

4.5. Combined/multiple: In this section one can include unilateral or bilateral presentation of isolated probably malignant findings. 4.6. Others: Includes any finding in the normal, benign or probably benign category which is appreciated simultaneously with probably malignant findings. (2)

5. MALIGNANT 5.1. Nodule/Mass: with spiculated, irregular, polylobulated or poorly defined contour associated with malignant microcalcifications, retraction of the skin or the nipple, or retraction of the pectoral muscle. 5.2. Tumoral structural alteration: associated with malignant microcalcifications, thickening and retraction of the skin or the nipple. 5.3. Tumoral asymmetry: associated with structural alteration, malignant microcalcifications, thickening and retraction of the skin or the nipple. 5.4. Skin/nipple alterations: Includes items of clinical-radiological diagnosis. 5.4.1. Inflammatory carcinoma: Peau dorange, inflammatory signs, associated with tumor or tumoral asymmetry, malignant microcalcifications, structural alterations and axillary adenopathies. 5.4.2. Pagets disease: Eczema of the nipple, either isolated or associated with a nodule, mass or malignant tumoral asymmetry, or with malignant microcalcifications. 5.5. Combined/multiple: These lesions are combinations of probably malignant lesions, with or without alterations of the skin, nipple, retraction of the pectoral muscle and on occasions with axillary adenopathies. Malignant lesions can be multiple, unilateral or bilateral. 5.6. Others: Includes any finding in the normal, benign or probably benign category, found simultaneously with malignant findings. (3)

8. MISCELLANEOUS 8.1. Artefacts 8.2. Superimpositions 8.3. Foreign bodies 8.4. Mammary implants 8.5. Reductive surgery 8.6. Cystosarcoma phyllodes 8.7. Sarcomas 8.8. Linfomas 8.9. Metastasis originating outside the breast

1)

2)

3)

CODE FIELD OPEN TO THE RESULTS OF DIAGNOSTIC ALGORITHM WHICH INCLUDES ULTRASOUND, FNAB, CORE BIOPSY OR FOLLOW-UP. CODE FIELD OPEN TO THE RESULTS OF THE DIAGNOSTIC ALGORITHM WHICH INCLUDES ULTRASOUND, FNAB, CORE BIOPSY OR FOLLOW-UP. CODE FIELD OPEN TO THE RESULTS OF DIAGNOSTIC ALGORITHM WHICH INCLUDES ULTRASOUND, FNAB, CORE BIOPSY OR FOLLOW-UP. 55

56

APPENDIX II

WORKSHEET

57

58

BIRADS vs. VBCSP Reading System (Note: BIRADS lexicon in brackets)


NAME: ................................................................................................................................ DATE: ......................................... LOCATION OF LESION RB LB RB LB

UPPER

OUTER

MLO

CC

MAMMOGRAPHIC FINDINGS
LB 1. Nodule / Mass (Masses) 2. Structural Alteration (Architectual distortion) 3. Calcifications (Calcifications) 4. Assymetry (Asymmetry of density)* 5. Skin/Nipple Alterations (Skin and nipple alterations) 6. Combined/Multiple (Associated findings and multiple lesions)** 7. Others (non-significant additional lesions) 8. Miscellaneous*** 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 RB

ASSESSMENT CATEGORIES
LB 1. Normal (Negative): 1.1. Fatty (Fat breast) 1.2. Dense (Dense breast) 2. 3. 4. 5.
*

RB 1 1. 1 1. 2 2 3 4 5

Benign (Benign finding) Probably benign (Probably benign finding) Probably malignant (Suspicious abnormality) Malignant (Highly suggestive of malignancy)

1 1. 1 1. 2 2 3 4 5

Includes density assymetry and assymetric ductal pattern. As special cases in BIRADS System, includes solitary dilated duct, asymmetric breast tissue and focal asymmetric density. ** Used for describing a combination of findings or when these are multiple. As associated findings in BIRADS system. *** Includes artefacts, implants and foreign bodies.

REMARKS: ............................................................................................................................................ ............................................................................................................................................ PROCEDURE TO BE IMPLEMENTED ............................................................................................................................................


59

60

NORMAL

61

62

CATEGORY 1. NORMAL

Fig. 1. Fatty breast. Scattered fibroglandular tissue. A lesion could not be concealed.

Fig. 2a. Dense breast. Pseudonodular fibroglandular tissue. Less sensitivity of mammography to detect the lesions.

63

CATEGORY 1. NORMAL

Fig. 2b. Plentiful fibroglandular tissue which could obscure neodensities, opacities and nodules.

Fig. 3. Intramammary lymph node with hilum notch and radiolucent centre (arrow)
64

CATEGORY 1. NORMAL

Fig. 4. Large-sized axillary lymph nodes with fatty centre.

Fig. 5. Magnification view. Intrammary lymph node showing the radiolucent fatty centre (arrow)

65

CATEGORY 1. NORMAL

Fig. 6. Large and dense metastatic axillary adenopathy. Oedema of the breast.

Fig. 7. Metastatic axillary adenopathy (arrowhead) due to breast cancer (arrows)


66

CATEGORY 1. NORMAL

Fig. 8. Skin lesion, wart. Well-defined contour with halo sign.

Fig. 9. Magnified view, skin lesion marked with barium. This is the same lesion shown in Figure 8.
67

CATEGORY 1. NORMAL

Fig. 10a. Sebaceous cyst.

Fig. 10b. Sebaceous cyst. Tangential magnified projection.

68

CATEGORY 1. NORMAL

Fig. 11a. Image of superimposed structures simulating a spiculated mass (arrow)

Fig. 11b. Spot film compression, the fibroglandular structures have been separated.

69

CATEGORY 1. NORMAL

Fig. 12.Vascular calcification.

Fig. 13. Magnified view showing vascular linear calcifications, in which the image of the vessel can be defined. Also, there is a group of dermic calcifications (arrow).
70

CATEGORY 1. NORMAL

Fig. 14a. Calcifications of sebaceous glands distributed in both breasts.

Fig. 14b. Magnified view of dermic calcifications in the axilla.


71

CATEGORY 1. NORMAL

Fig. 15. Amorphous califications secondary to surgery and radiotherapy. Thickening of the skin. Magnified projection.

Fig. 16. Microcystic calcifications. Magnified projection.

72

CATEGORY 1. NORMAL

Fig. 17. Asymmetric density due to fibroglandular tissue in the axilla (arrows)

Fig. 18. Vascular asymmetry due to collateral vessels in a thrombosis of axillary vein.

73

CATEGORY 1. NORMAL

Fig. 19. MLO projection. Asymmetric fibroglandular tissue in the left breast. Previous surgical resection in the right breast with a dystrophic calcification.

74

BENIGN

75

76

CATEGORY 2. BENIGN

Fig. 1. Calcifications of plasma cells mastitis which could be considered both as normal or benign finding.

Fig. 2. Probably benign nodule (1), simple cyst was confirmed by FNAB and pneumocystography (2). The classification will be benign nodule in future examinations.

77

CATEGORY 2. BENIGN

Fig. 3a. The contour of a low density nodule is partially concealed due to superimposed fibroglandular tissue (arrows). Magnified projection.

Fig. 3b. Ultrasound findings in a simple cyst.

78

CATEGORY 2. BENIGN

Fig. 4. Ultrasound findings in a probably benign nodule with solid characteristics.

Fig. 5. Two nodules (solid at ultrasound) with well-defined contour and diameter superior to 5 mm. The nodule in the left breast has benign calcifications (arrow) and must be considered definitively benign (fibroadenoma), and the nodule in the right breast must be classified as probably benign and followed-up.
79

CATEGORY 2. BENIGN

Fig. 6. Small nodule characteristically benign.

Fig. 7. Hamartoma. The nodule displayed a combination of water and fat densities surrounded by a pseudocapsule.

80

CATEGORY 2. BENIGN

Fig. 8a. Lipoma with a capsule in a fatty breast (arrows)

Fig. 8b. Lipoma with compression of the surrounding parenchyma in a dense breast.
81

CATEGORY 2. BENIGN

Fig. 9. Galactocele. Fluid-level of water and fat densities.

Fig. 10. Oil cyst after surgical biopsy (arrows)


82

CATEGORY 2. BENIGN

Fig. 11. Structural alteration of the parenchyma (arrows) due to surgical resection.

Fig. 12a. Calcified fibroadenoma in a fatty breast.


83

CATEGORY 2. BENIGN

Fig. 12b. Calcified fibroadenoma in a dense breast.

Fig. 13. Post-traumatic fat necrosis: bilateral calcificans macrocystic liponecrosis.

84

CATEGORY 2. BENIGN

Fig. 14. Calcified granulomas due to materials of surgical sutures (arrowheads)

Fig. 15. Ductal calcifications in plasma cells mastitis.


85

CATEGORY 2. BENIGN

Fig. 16a. Milk of calcium in cyst: Craniocaudal projection, blurred contour of particles (arrows)

Fig. 16b. Milk of calcium in cyst: Lateral Projection: typical cup of tea shape (arrows)
86

CATEGORY 2. BENIGN

Fig. 17. Diffuse benign bilateral microcalcifications.

Fig. 18a. Fibroglandular asymmetry with stability in the two-year follow-up (93/95), MLO projection (arrowheads)

87

CATEGORY 2. BENIGN

Fig. 18b. Fibroglandular asymmetry with stability in the two-year follow-up (93/95), CC projection (arrowheads)

Fig. 19a. Postsurgical asymmetry with mass effect.

88

CATEGORY 2. BENIGN

Fig. 19b. The ultrasound of lesion depicted in Figure 19a shows a hypoechoic mass. The histological diagnosis by core biopsy (14G, 3 cores) was granuloma of suture material.

Fig. 20a. MLO projection, the surgical resection in the right breast simulates an asymmetry of density in the left breast (also, artefacts that mimic calcium and technical problem, underexposed view due to deficient compression in the right breast)
89

CATEGORY 2. BENIGN

Fig. 20b. Postsurgical changes, CC projection showing retraction and thickening of skin.

Fig. 21. Diffuse thickening of skin. Retroareolar abscess.

90

CATEGORY 2. BENIGN

Fig. 22. Fibroadenoma with typical calcifications.

Fig. 23. Multiple bilateral nodules, simple cysts by ultrasound.

91

CATEGORY 2. BENIGN

Fig. 24. Calcified fibroadenoma, vascular calcifications and calcifications of microcystic liponecrosis.

92

PROBABLY BENIGN

93

94

CATEGORY 3. PROBABLY BENIGN

Fig. 1a. Nodule with well-defined contour.

Fig. 1b. The nodule shows solid characteristics in ultrasound. Malignancy was suspected from cytology (false positive result). The histological diagnosis was fibroadenoma.

95

CATEGORY 3. PROBABLY BENIGN

Fig. 2a. Nodule with partially visible contour. Another adjacent small nodule (arrow)

Fig. 2b. Ultrasound shows a solid, anechoic lesion with acoustic absorption and calcification. The cytological diagnosis was non-specific granuloma. No changes were detected in the follow-up (two years)
96

CATEGORY 3. PROBABLY BENIGN

Fig. 3. Nodule with lobulate contour. The cytological diagnosis was fibroadenoma. No changes were detected in the follow-up (three years)

Fig. 4. Ultrasound imaging of a intracystic papilloma.


97

CATEGORY 3. PROBABLY BENIGN

Fig. 5. Group of 8 microcalcifications with the same shape, size and density. No changes were detected in the follow-up (three years)

Fig. 6. Round-shaped small microcalcifications distributed in one lobule of the breast, the elements had the same shape, but different size and density and outline multiple groups of 4-6 particles. Despite this lesion being considered probably benign, women prefer the biopsy and the histological result was calcifications in ductal and lobular atrophy.
98

CATEGORY 3. PROBABLY BENIGN

Fig. 7. Group of heterogeneous, amorphous and well defined calcifications, coarse elements with homogeneous density, the particle size was more than 1 mm. The cytology result was benign. No changes were observed in follow-up (three years)

Fig. 8a. Group of coarse, amorphous and heterogeneous calcifications, with other elements of lower density and linear shape (arrows)
99

CATEGORY 3. PROBABLY BENIGN

Fig. 8b. An increase in particles was detected (arrows) in the 6-months follow-up. The histological diagnosis was calcifications in cysts, fibrosis and hyalinosis.

Fig. 9a. Normal mammogram prior to HRT (hormone replacement therapy)


100

CATEGORY 3. PROBABLY BENIGN

Fig. 9b. Asymmetry of density that was developed in a patient with HRT. The palpation and ultrasound were negative. No changes were seen in the subsequent follow-up.

Fig. 10a. Palpable asymmetric density located in the lower-inner quadrant (arrowheads)

101

CATEGORY 3. PROBABLY BENIGN

Fig. 10b. An hypoechoic mass was depicted by ultrasound. The cytology was positive for malignant cells and the histological diagnosis was IDC (invasive ductal carcinoma)-T2, N0.

Fig. 11a. Asymmetric ductal pattern.


102

CATEGORY 3. PROBABLY BENIGN

Fig. 11b. The galactography shows dilated ducts with an intra-luminal filling defect. The histological diagnosis was intraductal papilloma.

Fig. 12. Multiple bilateral nodules in a patient with HRT. Ultrasound shows simple cysts.
103

CATEGORY 3. PROBABLY BENIGN

Fig. 13. Diffuse bilateral calcifications.

Fig. 14a. Elliptical and well-defined nodule, with a size of 9 mm (arrowhead) that was considered probably benign and followed-up.
104

CATEGORY 3. PROBABLY BENIGN

Fig. 14b. The nodule had grown (14 mm.) after six months. The histological diagnosis was IDC (arrow)

Fig. 15a. Group of microcalcifications with stability in two years (arrow)

105

CATEGORY 3. PROBABLY BENIGN

Fig. 15b. The microcalcifications displayed changes three years later (arrow). The histological diagnosis was IDC.

Fig. 16a. A 9 mm, round and lobulate nodule.

106

CATEGORY 3. PROBABLY BENIGN

Fig. 16b. Ultrasound shows indeterminate findings (not definitively solid or liquid lesion)

Fig. 16c. Stereotaxic pneumocystography shows the incomplete filling of lesion. The aspirate was bloody and the cytological diagnosis was positive to malignant cells. The histological diagnosis was a 3 mm intracystic ductal carcinoma in situ.

107

CATEGORY 3. PROBABLY BENIGN

Fig. 17a. Non-palpable asymmetric density, visible only in the MLO projection.

Fig. 17b. The ultrasound found a mass unseen in the asymmetric density. The cytological diagnosis was positive for malignant cells. The histological diagnosis was an IDC (10 mm.-size)
108

PROBABLY MALIGNANT

109

Note.- All the cases described in the figures are histologically verified as carcinoma.

110

CATEGORY 4. PROBABLY MALIGNANT

Fig. 1a. Spiculated mass. The mass is clearly seen in the CC projection.

Fig. 1b. The lesion was less perceptible in the MLO projection (arrow)

111

CATEGORY 4. PROBABLY MALIGNANT

Fig. 2. Mass with irregular contour.

Fig. 3. Mass with comet tail sign due to the retracted parenchyma (arrows). Magnified projection.

112

CATEGORY 4. PROBABLY MALIGNANT

Fig. 4. Mass with brush-edged type of spiculation (stellate tumours)

Fig. 5a. Areolar spiculated mass: The spiculation is clearly seen in CC projection.

113

CATEGORY 4. PROBABLY MALIGNANT

Fig. 5b. Areolar spiculated mass: the spiculation is not clearly seen in MLO projection (arrows)

Fig. 6a. Mass with irregular contour. CC projection.

114

CATEGORY 4. PROBABLY MALIGNANT

Fig. 6b. Mass with irregular contour. MLO projection. Axillary adenopathies.

Fig. 7a. Small spiculated mass. MLO projection.


115

CATEGORY 4. PROBABLY MALIGNANT

Fig. 7b. Small spiculated mass. Magnified projection.

Fig. 8. Mass with irregular and indistinct contour.


116

CATEGORY 4. PROBABLY MALIGNANT

Fig. 9a. Small mass, partially hidden by the parenchyma. CC projection.

Fig. 9b. The focal compression shows the indistinct contour.


117

CATEGORY 4. PROBABLY MALIGNANT

Fig. 10. Mass with microlobulate contour: mucinous carcinoma.

118

CATEGORY 4. PROBABLY MALIGNANT

Fig. 11a. Small ill-defined low density mass. MLO projection (arrows)

Fig. 11b. Small ill-defined low density mass. The magnification view shows the margins of tumour up better.
119

CATEGORY 4. PROBABLY MALIGNANT

Fig. 12. Mass with partially ill-defined contour: mucinous or colloid carcinoma.

Fig. 13. Star lesion.

120

CATEGORY 4. PROBABLY MALIGNANT

Fig. 14a. The architectural distortion (star lesion) is difficult to perceive in a dense breast. CC projection (arrows)

Fig. 14b. The star lesion was confirmed after spot magnification view (arrows)

121

CATEGORY 4. PROBABLY MALIGNANT

Fig. 15a. Asymmetric tissue with structural alteration: lobular invasive carcinoma. MLO projection (arrows)

Fig. 15b. CC projection (arrows)

122

CATEGORY 4. PROBABLY MALIGNANT

Fig. 15c. Focal compression displays the asymmetric area.

Fig. 16a. Probably malignant microcalcifications (only seen with magnifying glass). CC projection (arrows)
123

CATEGORY 4. PROBABLY MALIGNANT

Fig. 16b. The microcalcifications are shown up well in the spot magnification view (arrows)

Fig. 17. Probably malignant microcalcifications.


124

CATEGORY 4. PROBABLY MALIGNANT

Fig. 18. Heterogeneous group of microcalcifications (incidental superposition with a simple cyst)

Fig. 19. Heterogeneous group of microcalcifications.

125

CATEGORY 4. PROBABLY MALIGNANT

Fig. 20. Innumerable granular microcalcifications.

Fig. 21. Casting microcalcifications with segmental distribution (arrows)


126

CATEGORY 4. PROBABLY MALIGNANT

Fig. 22. Casting and granular microcalcifications with regional distribution.

Fig. 23a. Focal asymmetric density. MLO projection (arrows)

127

CATEGORY 4. PROBABLY MALIGNANT

Fig. 23b. Focal asymmetric density with architectural distortion. CC projection (arrows)

Fig. 24. Large, high density, tumoral asymmetry.

128

CATEGORY 4. PROBABLY MALIGNANT

Fig. 25a. Non-palpable asymmetry. CC projection (arrows)

Fig. 25b. Focal compression view, asymmetry with mass effect.


129

CATEGORY 4. PROBABLY MALIGNANT

Fig. 25c. A hypoechoic mass was depicted by ultrasound.

Fig. 26. Small bilateral spiculated masses, bilateral carcinomas (arrows)

130

MALIGNANT

131

Note.- All the cases described in the figures are histologically verified as carcinoma.

132

CATEGORY 5. MALIGNANT

Fig.1.Spiculated tumour with retraction of the skin.

Fig. 2.Spiculated tumour with casting microcalcifications and retraction of the pectoral muscle.

133

CATEGORY 5. MALIGNANT

Fig. 3.Spiculated tumour with retraction of the nipple.

Fig. 4.Spiculated mass with casting microcalcifications.

134

CATEGORY 5. MALIGNANT

Fig. 5.Spiculated mass with heterogeneous microcalcifications and thickening and retraction of the skin.

Fig. 6. Palpable tumoral density and architectural distortion with microcalcifications.

135

CATEGORY 5. MALIGNANT

Fig. 7 a. Asymmetrical tumoral density associated with palpable mass. MLO projection.

Fig. 7 b. Diffuse asymmetric high density in the left breast. CC projection.

136

CATEGORY 5. MALIGNANT

Fig. 8. Inflammatory carcinoma. Heterogeneous microcalcifications with thickening of the skin and nipple, associated with clinical signs (see colour photo 1, p. 139)

Fig. 9 a. Inflammatory carcinoma. Skin, nipple and trabecular thickening. MLO projection.

137

CATEGORY 5. MALIGNANT

Fig. 9 b. CC Projection.

Fig. 10. Retroareolar masses in a case with Paget disease (see colour photo 2, p. 139)

138

CATEGORY 5. MALIGNANT

Photo 1. Inflammatory carcinoma.

Photo 2. Eczema of the nipple in Pagets carcinoma.

139

140

140

MISCELLANEOUS

141

142

MISCELLANEOUS

Fig. 1. Artefacts that simulate calcifications produced by deodorant creams in the axilla.

Photo 1. Skin ulcers produced by the application of an abrasive substance.

143

MISCELLANEOUS

Fig. 2. Foreign body: fragment of surgical needle.

Fig. 3. Intramammary projectiles: shotgun pellets.

144

MISCELLANEOUS

Fig. 4. Calcifications of suture materials in knot form.

Fig. 5. Fragments of a hook wire.


145

MISCELLANEOUS

Fig. 6. Pacemaker.

Fig. 7. Dacron sheath of Hickman catheters.


146

MISCELLANEOUS

Fig. 8. Silicone balls injected for aesthetic purposes.

Fig. 9a. Submuscular implants. MLO projection showing the underlying muscle situation (arrows)
147

MISCELLANEOUS

Fig. 9b. Submuscular implants. CC projection, the prosthesis has been displaced by Eklunds handling.

Fig. 10a. Subglandular implants. MLO projection showing the situation of the prosthesis.
148

MISCELLANEOUS

Fig.10b. Subglandular implants. CC projection, the prosthesis has been displaced by Eklunds handling.

Fig. 11. Empty implant after breakage with loss of the content.

149

MISCELLANEOUS

Fig. 12a. Reduction mammoplasty, with anomalous distribution of the fibroglandular tissue and pseudonodules. MLO projection.

Fig. 12b. CC projection.


150

MISCELLANEOUS

Fig. 13. Osteosarcoma of the breast, solid bone matrix and osseous spiculations.

Fig. 14. Cystosarcomas phyllode.


151

MISCELLANEOUS

Fig. 15a. Lymphoma of the breast. The mammogram displayed a dense asymmetrical breast tissue with mass effect.

Fig. 15b. CT: Diffuse invasion of the parenchyma.


152

MISCELLANEOUS

Fig. 15c. Axillary adenopathies.

Fig. 16. Multiple masses, metastasis from a uterine sarcoma.


153

154

N D E X

INDEX OF FIGURES
CHAPTER II . CATEGORY 1. NORMAL Fig. 1. Fatty breast. Scattered fibroglandular tissue. A lesion could not be concealed. ....................... Fig. 2a. Dense breast. Pseudonodular fibroglandular tissue. Less sensitivity of mammography to detect the lesions. ................................................................................................................................. Fig. 2b. Plentiful fibroglandular tissue which could obscure neodensities, opacities and nodules .......... Fig. 3. Intramammary lymph node with hilum notch and radiolucent centre (arrow) ......................... Fig. 4. Large-sized axillary lymph nodes with fatty centre ............................................................... Fig. 5. Magnification view. Intrammary lymph node showing the radiolucent fatty centre (arrow) ....... Fig. 6. Large and dense metastatic axillary adenopathy. Oedema of the breast. ............................... Fig. 7. Metastatic axillary adenopathy (arrowhead) due to breast cancer (arrows) .............................. Fig. 8. Skin lesion, wart. Well-defined contour with halo sign. ........................................................ Fig. 9. Magnified view, skin lesion marked with barium. This is the same lesion shown in Figure 8. ... Fig. 10a. Sebaceous cyst ............................................................................................................. Fig. 10b. Sebaceous cyst. Tangential magnified projection. ............................................................. Fig. 11a. Image of superimposed structures simulating a spiculated mass (arrow) .............................. Fig. 11b. Spot film compression, the fibroglandular structures have been separated. ......................... Fig. 12. Vascular calcification ....................................................................................................... Fig. 13. Magnified view showing vascular linear calcifications, in which the image of the vessel can be defined. Also, there is a group of dermic calcifications (arrow). ............................................. Fig. 14a. Calcifications of sebaceous glands distributed in both breasts ............................................. Fig. 14b. Magnified view of dermic calcifications in the axilla .......................................................... Fig. 15. Amorphous califications secondary to surgery and radiotherapy. Thickening of the skin. Magnified projection. ................................................................................................................... Fig. 16. Microcystic calcifications. Magnified projection. ................................................................. Fig. 17. Asymmetric density due to fibroglandular tissue in the axilla (arrows) ................................... Fig. 18. Vascular asymmetry due to collateral vessels in a thrombosis of axillary vein ......................... Fig. 19. MLO projection. Asymmetric fibroglandular tissue in the left breast. Previous surgical resection in the right breast with a dystrophic calcification. .................................... 63 63 64 64 65 65 66 66 67 67 68 68 69 69 70 70 71 71 72 72 73 73 74

CHAPTER III. CATEGORY 2. BENIGN Fig. 1. Calcifications of plasma cells mastitis which could be considered both as normal or benign finding ............................................................................................................................. Fig. 2. Probably benign nodule (1), simple cyst was confirmed by FNAB and pneumocystography (2). The classification will be benign nodule in future examinations. ................ Fig. 3a. The contour of a low density nodule is partially concealed due to superimposed fibroglandular tissue (arrows). Magnified projection ......................................................................... Fig. 3b. Ultrasound findings in a simple cyst .................................................................................. Fig. 4. Ultrasound findings in a probably benign nodule with solid characteristics .............................. Fig. 5. Two nodules (solid at ultrasound) with well-defined contour and diameter superior to 5 mm. The nodule in the left breast has benign calcifications (arrow) and must be considered definitively benign (fibroadenoma), and the nodule in the right breast must be classified as probably benign and followed-up .......................................................................................................................... Fig. 6. Small nodule characteristically benign ................................................................................. Fig. 7. Hamartoma. The nodule displayed a combination of water and fat densities surrounded by a pseudocapsule ............................................................................................................................ Fig. 8a. Lipoma with a capsule in a fatty breast (arrows) ................................................................. Fig. 8b. Lipoma with compression of the surrounding parenchyma in a dense breast ........................ Fig. 9. Galactocele. Fluid-level of water and fat densities ................................................................ Fig. 10. Oil cyst after surgical biopsy (arrows) ................................................................................ Fig. 11. Structural alteration of the parenchyma (arrows) due to surgical resection ............................ Fig. 12a. Calcified fibroadenoma in a fatty breast ........................................................................... Fig. 12b. Calcified fibroadenoma in a dense breast ......................................................................... Fig. 13. Post-traumatic fat necrosis: bilateral calcificans macrocystic liponecrosis ..............................

77 77 78 78 79

79 80 80 81 81 82 82 83 83 84 84

155

N D E X

Fig. 14. Calcified granulomas due to materials of surgical sutures (arrowheads) ................................. Fig. 15. Ductal calcifications in plasma cells mastitis ....................................................................... Fig. 16a. Milk of calcium in cyst: Craniocaudal projection, blurred contour of particles (arrows) .......... Fig. 16b. Milk of calcium in cyst: Lateral Projection: typical cup of tea shape (arrows) ....................... Fig. 17. Diffuse benign bilateral microcalcifications ......................................................................... Fig. 18a. Fibroglandular asymmetry with stability in the two-year follow-up (93/95), MLO projection (arrowheads) ....................................................................................................... Fig. 18b. Fibroglandular asymmetry with stability in the two-year follow-up (93/95), CC projection (arrowheads) .......................................................................................................... Fig. 19a. Postsurgical asymmetry with mass effect ......................................................................... Fig. 19b. The ultrasound of lesion depicted in Figure 19a shows a hypoechoic mass. The histological diagnosis by core biopsy (14G, 3 cores) was granuloma of suture material ................ Fig. 20a. MLO projection, the surgical resection in the right breast simulates an asymmetry of density in the left breast (also, artefacts that mimic calcium and technical problem, underexposed view due to deficient compression in the right breast) ................................................ Fig. 20b. Postsurgical changes, CC projection showing retraction and thickening of skin ................... Fig. 21. Diffuse thickening of skin. Retroareolar abscess. ................................................................ Fig. 22. Fibroadenoma with typical calcifications ............................................................................ Fig. 23. Multiple bilateral nodules, simple cysts by ultrasound .......................................................... Fig. 24. Calcified fibroadenoma, vascular calcifications and calcifications of microcystic liponecrosis ...

85 85 86 86 87 87 88 88 89

89 90 90 91 91 92

CHAPTER IV. CATEGORY 3. PROBABLY BENIGN Fig. 1a. Nodule with well-defined contour ...................................................................................... Fig. 1b. The nodule shows solid characteristics in ultrasound. Malignancy was suspected from cytology (false positive result). The histological diagnosis was fibroadenoma ...................................... Fig. 2a. Nodule with partially visible contour. Another adjacent small nodule (arrow) .......................... Fig. 2b. Ultrasound shows a solid, anechoic lesion with acoustic absorption and calcification. The cytological diagnosis was non-specific granuloma. No changes were detected in the follow-up (two years) .................................................................................................................... Fig. 3. Nodule with lobulate contour. The cytological diagnosis was fibroadenoma. No changes were detected in the follow-up (three years) ................................................................. Fig. 4. Ultrasound imaging of a intracystic papilloma ...................................................................... Fig. 5. Group of 8 microcalcifications with the same shape, size and density. No changes were detected in the follow-up (three years) ................................................................. Fig. 6. Round-shaped small microcalcifications distributed in one lobule of the breast, the elements had the same shape, but different size and density and outline multiple groups of 4-6 particles. Despite this lesion being considered probably benign, women prefer the biopsy and the histological result was calcifications in ductal and lobular atrophy. .............................. Fig. 7. Group of heterogeneous, amorphous and well defined calcifications, coarse elements with homogeneous density, the particle size was more than 1 mm. The cytology result was benign. No changes were observed in follow-up (three years). ..................................................................... Fig. 8a. Group of coarse, amorphous and heterogeneous calcifications, with other elements of lower density and linear shape (arrows) ......................................................................................... Fig. 8b. An increase in particles was detected (arrows) in the 6-months follow-up. The histological diagnosis was calcifications in cysts, fibrosis and hyalinosis. ..................................... Fig. 9a. Normal mammogram prior to HRT (hormone replacement therapy) ................................... Fig. 9b. Asymmetry of density that was developed in a patient with HRT. The palpation and ultrasound were negative. No changes were seen in the subsequent follow-up ....... Fig. 10a. Palpable asymmetric density located in the lower-inner quadrant (arrowheads) .................... Fig. 10b. An hypoechoic mass was depicted by ultrasound. The cytology was positive for malignant cells and the histological diagnosis was IDC (invasive ductal carcinoma)-T2, N0 ................. Fig. 11a. Asymmetric ductal pattern ............................................................................................. Fig. 11b. The galactography shows dilated ducts with an intra-luminal filling defect. The histological diagnosis was intraductal papilloma ....................................................................... Fig. 12. Multiple bilateral nodules in a patient with HRT. Ultrasound shows simple cysts .................... Fig. 13. Diffuse bilateral calcifications ........................................................................................... 95 95 96

96 97 97 98

98

99 99 100 100 101 101 102 102 103 103 104

156

I Fig. 14a. Elliptical and well-defined nodule, with a size of 9 mm (arrowhead) that was considered probably benign and followed-up. ................................................................................. Fig. 14b. The nodule had grown (14 mm.) after six months. The histological diagnosis was IDC (arrow) .................................................................................... Fig. 15a. Group of microcalcifications with stability in two years (arrow) ........................................... Fig. 15b.The microcalcifications displayed changes three years later (arrow). The histological diagnosis was IDC. .............................................................................................. Fig. 16a. A 9 mm, round and lobulate nodule ................................................................................ Fig. 16b. Ultrasound shows indeterminate findings (not definitively solid or liquid lesion) .................... Fig. 16c. Stereotaxic pneumocystography shows the incomplete filling of lesion. The aspirate was bloody and the cytological diagnosis was positive to malignant cells. The histological diagnosis was a 3 mm intracystic ductal carcinoma in situ .................................... Fig. 17a. Non-palpable asymmetric density, visible only in the MLO projection ................................. Fig. 17b. The ultrasound found a mass unseen in the asymmetric density. The cytological diagnosis was positive for malignant cells. The histological diagnosis was an IDC (10 mm.-size) ......................................................................

N D E X

104 105 105 106 106 107

108 108

108

CHAPTER V. CATEGORY 4. PROBABLY MALIGNANT Note: All the cases described in the figures are histologically verified as carcinoma. Fig. 1a. Spiculated mass. The mass is clearly seen in the CC projection ........................................... Fig. 1b. The lesion was less perceptible in the MLO projection (arrow) ............................................. Fig. 2. Mass with irregular contour ............................................................................................... Fig. 3. Mass with comet tail sign due to the retracted parenchyma (arrows). Magnified projection .... Fig. 4. Mass with brush-edged type of spiculation (stellate tumours) ............................................... Fig. 5a. Areolar spiculated mass: The spiculation is clearly seen in CC projection ............................. Fig. 5b. Areolar spiculated mass: the spiculation is not clearly seen in MLO projection (arrows) .......... Fig. 6a. Mass with irregular contour. CC projection ........................................................................ Fig. 6b. Mass with irregular contour. MLO projection. Axillary adenopathies .................................... Fig. 7a. Small spiculated mass. MLO projection ............................................................................. Fig. 7b. Small spiculated mass. Magnified projection ...................................................................... Fig. 8. Mass with irregular and indistinct contour ........................................................................... Fig. 9a. Small mass, partially hidden by the parenchyma. CC projection .......................................... Fig. 9b. The focal compression shows the indistinct contour ........................................................... Fig. 10. Mass with microlobulate contour: mucinous carcinoma ...................................................... Fig. 11a. Small ill-defined low density mass. MLO projection (arrows) .............................................. Fig. 11b. Small ill-defined low density mass. The magnification view shows the margins of tumour up better ......................................................................................................................... Fig. 12. Mass with partially ill-defined contour: mucinous or colloid carcinoma ................................. Fig. 13. Star lesion ...................................................................................................................... Fig. 14a. The architectural distortion (star lesion) is difficult to perceive in a dense breast. CC projection (arrows) ................................................................................................................. Fig. 14b. The star lesion was confirmed after spot magnification view (arrows) ................................. Fig. 15a. Asymmetric tissue with structural alteration: lobular invasive carcinoma. MLO projection (arrows) .............................................................................................................. Fig. 15b. CC projection (arrows) ................................................................................................... Fig. 15c. Focal compression displays the asymmetric area .............................................................. Fig. 16a. Probably malignant microcalcifications (only seen with magnifying glass). CC projection (arrows) ................................................................................................................. Fig. 16b. The microcalcifications are shown up well in the spot magnification view (arrows) ............... Fig. 17. Probably malignant microcalcifications .............................................................................. Fig. 18. Heterogeneous group of microcalcifications (incidental superposition with a simple cyst) ....... Fig. 19. Heterogeneous group of microcalcifications ...................................................................... Fig. 20. Innumerable granular microcalcifications ........................................................................... Fig. 21. Casting microcalcifications with segmental distribution (arrows) ........................................... Fig. 22. Casting and granular microcalcifications with regional distribution ....................................... 111 111 112 112 113 113 114 114 114 115 115 116 117 117 118 119 119 120 120 121 121 122 122 123 123 124 124 125 125 126 126 127

157

N D E X

Fig. 23a. Focal asymmetric density. MLO projection (arrows) .......................................................... Fig. 23b. Focal asymmetric density with architectural distortion. CC projection (arrows) .................... Fig. 24. Large, high density, tumoral asymmetry ........................................................................... Fig. 25a. Non-palpable asymmetry. CC projection (arrows) ............................................................. Fig. 25b. Focal compression view, asymmetry with mass effect ....................................................... Fig. 25c. A hypoechoic mass was depicted by ultrasound ............................................................... Fig. 26. Small bilateral spiculated masses, bilateral carcinomas (arrows) ............................................ CHAPTER VI. CATEGORY 5. MALIGNANT Note: All the cases described in the figures are histologically verified as carcinoma. Fig. 1. Spiculated tumour with retraction of the skin ....................................................................... Fig. 2. Spiculated tumour with casting microcalcifications and retraction of the pectoral muscle ......... Fig. 3. Spiculated tumour with retraction of the nipple ................................................................... Fig. 4. Spiculated mass with casting microcalcifications .................................................................. Fig. 5. Spiculated mass with heterogeneous microcalcifications and thickening and retraction of the skin ................................................................................................................... Fig. 6. Palpable tumoral density and architectural distortion with microcalcifications .......................... Fig. 7a. Asymmetrical tumoral density associated with palpable mass. MLO projection ...................... Fig. 7b. Diffuse asymmetric high density in the left breast. CC projection ......................................... Fig. 8. Inflammatory carcinoma. Heterogeneous microcalcifications with thickening of the skin and nipple, associated with clinical signs (see colour photo 1, p. 139) .............................. Fig. 9a. Inflammatory carcinoma. Skin, nipple and trabecular thickening. MLO projection ................. Fig. 9b. CC Projection ................................................................................................................. Fig. 10. Retroareolar masses in a case with Paget disease (see colour photo 2, p.139) ...................... Photo 1. Inflammatory carcinoma ................................................................................................ Photo 2. Eczema of the nipple in Pagets carcinoma ...................................................................... CHAPTER VII. MISCELLANEOUS Fig. 1. Artefacts that simulate calcifications produced by deodorant creams in the axilla ..................... Photo 1.Skin ulcers produced by the application of an abrasive substance ........................................ Fig. 2. Foreign body: fragment of surgical needle ........................................................................... Fig. 3. Intramammary projectiles: shotgun pellets ........................................................................... Fig. 4. Calcifications of suture materials in knot form ..................................................................... Fig. 5. Fragments of a hook wire .................................................................................................. Fig. 6. Pacemaker ....................................................................................................................... Fig. 7. Dacron sheath of Hickman catheters .................................................................................. Fig. 8. Silicone balls injected for aesthetic purposes ........................................................................ Fig. 9a. Submuscular implants. MLO projection showing the underlying muscle situation (arrows) ...... Fig. 9b. Submuscular implants. CC projection, the prosthesis has been displaced by Eklunds handling .................................................................................................................... Fig. 10a. Subglandular implants. MLO projection showing the situation of the prosthesis .................. Fig. 10b. Subglandular implants. CC projection, the prosthesis has been displaced by Eklunds handling .................................................................................................................... Fig. 11. Empty implant after breakage with loss of the content ........................................................ Fig. 12a. Reduction mammoplasty, with anomalous distribution of the fibroglandular tissue and pseudonodules. MLO projection .................................................................................... Fig. 12b. CC projection ............................................................................................................... Fig. 13. Osteosarcoma of the breast, solid bone matrix and osseous spiculations .............................. Fig. 14. Cystosarcomas phyllodes ................................................................................................. Fig. 15a. Lymphoma of the breast. The mammogram displayed a dense asymmetrical breast tissue with mass effect ........................................................................................................ Fig. 15b. CT: Diffuse invasion of the parenchyma .......................................................................... Fig. 15c. Axillary adenopathies .................................................................................................... Fig. 16. Multiple masses, metastasis from a uterine sarcoma ...........................................................

127 128 128 129 129 130 130

133 133 134 134 135 135 136 136 137 137 138 138 139 139

143 143 144 144 145 145 146 146 147 147 148 148 149 149 150 150 151 151 152 152 153 153

158

N D E X

INDEX OF TERMS

A abscess, 26, 41 accessory mammary tissue, 20 adenosis, sclerosing adenosis, 34, 35, 40 alteration, alterations, 17, 19, 20, 24-26, 30, 34, 35, 39, 41, 45, 51, 52 in benign category, 26 in malignant category, 40 in normal category, 20 of skin/nipple, 20, 26, 40, 41, 51, 52 amorphous (see calcifications) anechoic (lesion in ultrasound), 23 angiosarcoma, 46 annular (see calcifications) antimitotic (cutaneous lesion by application of), 43 areolar (subareolar), 19, 20, 24, 30, 39, 41, 45 artefact, 43, 51 and superimposing, 43 by tattooing, 43 assessment, 49 asymmetric ductal pattern, 30 asymmetry, 20, 25, 26, 30, 35, 36, 40, 45, 50, 51 asymptomatic, 20, 39, 43, 44 characteristics of benignity, 29 in benign category, 25 in malignant category, 40 in normal category, 20 in probably benign category, 30 in probably malignant category, 35 isodense, 20 of volume, 20 tumoral, 35 vascular, 20 axillary adenophaties (see lymph node) tail, 18

B barium (as marker), 19 barium sulphate (artefact by), 43 benign pathology, 18 benign, benignity, 11, 14, 17, 18, 20, 23, 46, 47, 49, 50-52 bibliography, 15, 21, 27, 31, 37, 42, 47 bilateral lesion (probably benign), 30 lymphoma, 46 mammography, 49 microcalcifications, 25, 30 oedema, 19, 26, 40, 47 biopsy, 18, 20, 23, 24, 26, 29-31, 33-36, 41, 46 directed by coordinates, 31 directed by stereotaxy, 31, 36 directed by ultrasound, 36

159

N D E X

fine needle aspiration (see FNAB) with hook wire (harpoon), 36 tumorectomy, 20 BI-RADS, 14, 15, 30, 49-52 blurred (see calcifications) blurredness (poorly-defined contour), 34 branching (see ramified) breast cancer, 7, 13, 14, 17, 24, 35, 40, 41, 44, 45, 49, 52 breast cancer not visible in the mammography, 13 Breast Cancer Screening Facility (BCSF), 7 breast committee, 41 brush-edge (of spiculated mass), 34

C calcifications (microcalcifications), amorphous, 30 and granuloma, 25 and metastasis, 47 and pacemaker, 44 and sarcoma, 46 annular, 20 artefacts mimicking, 43 as only sign of cancer, 35 associated with star lesion and cutaneous retraction, 36 characters of benignity, 29 characters of malignity, 35 cicatricial, 20, 51 coarse, 20 curvilinear, 20 dermic, 19 ductal (intraductal), 25, 35 granular, 35, 40 homogeneous, 30 in benign category, 25 in corn-flakes, 54 in knot shape, 20 in liponecrosis, 20, 23, 25 in malignant category, 40 in multiple groups, 30 in normal category, 19 in probably benign category, 30 in probably malignant category, 35 indeterminate, 30 intraductal (see ductal) ill-defined (or blurred), 25, 30 irregular, 20, 35, 40 linear, 19, 20, 25, 35, 40, 43 location of, 19 microcystic, 20 oval, 30 periductal, 25 pleomorphic, 30, 35 polymorphous, 25 postoperative, 20 ramified, 35 round, 20

160

I small, 35 spherical, 25, 30 tubular, 25 vascular, 19 with radiolucent centre, 19, 20 calcify, 19, 25, 43 calcium (deposits of, salts of), 25, 35, 51 calcium milk in cyst, 25 calcium salts in hard waters (artefact by), 43 capsule, 24, 45 carcinoma medullary of the thyroids, 47 bronchial (metastasis of ), 47 ductal, in situ (DISC), 35 infiltrating ductal (IDC), 35 inflammatory, 39-41 lobular infiltrating, 35 medullary, 34 mucinous or colloid, 34 of the ovary (metastasis of), 47 papillary, 34 category 1, Normal, 17 2, Benign, 23 3, Probably benign, 29 4, Probably malignant, 33 5, Malignant, 39 CC (see craniocaudal) changes postinfectious, 25 postmenopausal, 19 postoperative, 20, 21, 25, 26, 34, 35, 40 post-traumatic, 24-26 cicatricial (see calcifications) sequels, 20 clinical examination, physical examination, 18, 24, 26, 29, 36, 39, 49 coarse (see calcifications) collateral circulation (a form of asymmetry), 20 combined /multiple, 26, 30, 36, 41, 51 comet tail (sign of), 33, 34, 54 complementary studies, 14, 23 conduct generated by the benign category, 23 generated by the malignant category, 41 generated by the probably benign category, 30 generated by the probably malignant category, 36 contour (of a lesion) blurred, 33, 34, 46 irregular, 33, 34 microlobulated, 33, 34 sharp, 24, 29 spiculated, 33, 34, 39, 46 core needle biopsy, cylinder biopsy, 26, 29, 31, 33, 34, 36, 52 craniocaudal projection (CC), 25, 40, 45, 49, 50 creams, 19, 43 cutaneous pore, 19 cutaneous thickening, 21 ulceration (in advanced cancer), 41 cyst, 19, 20, 23-26, 29, 46, 52 characteristics in ultrasound, 23 epidermal, inclusion, 19 sebaceous, 19 cytological, cytology, 14, 29, 31, 41, 47, 49, 52

N D E X

161

N D E X

D dense breast, 17, 18, 25, 34, 35, 40, 52 density, fat, 24 focal, 30 high, 18 homogeneous, 24, 25 low, 18, 19, 24 mixed, 17-19, 24 tumoral asymmetry (see asymmetry) water, 24 deodorant (artefact by), 19, 43 dermatomyositis (in relation to prostheses), 45 dermic (see calcifications) creams, 19 lymphatics (infiltrating by), 41 desmoplastic reaction (see fibrosis, elastosis) diagnostic algorithm, 55 dictionary of language, 14 difficulty in early diagnosis due to the prostheses, 45 dilated duct, in probably benign asymmetry, 30 in the Paget disease, 41 disease, 40, 41, 44-46 metastatic, 41 of the collagen (immune), 18, 44, 45 distortion of the architecture (see structural alteration) Dracon sheath (superimposing by), 44 ductal (see calcifications, carcinoma)

E early sign of cancer (microcalcifications as), 35 effect of volume or volumetric effect, 30 Efudix (ulcers by), 43 Eklund (handling in prostheses), 45 elastosis (see fibrosis, desmoplastic reaction) epithelial (surface of the nipple), 41 excisional biopsy, 29, 36 extra-abdominal desmoide (as a cause of spiculated mass), 34 exudation (in prosthesis), 45

F fat (see density) fatty breast, 18, 24, 40 fatty infiltration (in lymph node), 18 fatty necrosis, 20, 24-26, 34, 40 fatty saponification (in cystic liponecrosis), 25 FDA (Food and Drug Administration), 44 fibroadenolipoma, 24 fibroadenoma, calcified fibroadenoma, 23-26, 46, 47 fibroglandular (element, tissue, structure, parenchyma), 17, 19, 35, 50, 51 fibrosis (elastosis), 34, 39, 45 cicatricial, 34

162

I fibrous capsule, 45 fibrous contraction (in prostheses), 45 fingerprint (artefact by), 43 fluid level (sign in the galactocele), 24 FNAB (fine needle aspiration biopsy), 26, 31, 33, 34, 36, 52 foreign bodies, 25, 43, 44, 51 fragment of needle (as foreign body), 44

N D E X

G galactocele, 24 galactography, 30 galactophorous duct, 40, 41 glandular architecture, mammary (distortion of ), 34, 35, 40, 51 glandular tissue (mammary), 17, 24, 29, 40, 49-51 gold salts (speudocalcifications by), 43 granular (calcifications), 35, 40 granular cell tumour (as cause of spiculated mass), 34 granuloma (to foreign body), 25

H haematoma, 25 hair (artefact by), 43 halo (sign of), 19, 29 hamartoma (see fibroadenolipoma) Hickman catheter, 44 high density (lesion), 18, 19, 33, 39 hilar groove in lymph node, hilum, fatty radiolucent hilum, 18 histological, 14, 17, 23, 25, 26, 29, 31, 36, 40, 41, 46, 47, 49, 52 homogeneous (see calcifications) hook wire (location device), 36, 43, 44, 52 hormone replacement therapy (HRT), 17 hydrogel (in prostheses), 44 hypoechoic (in ultrasound), 47

I IDC (see infiltrating ductal carcinoma) implant, 45, 51 in corn-flakes (see calcifications) indeterminate (see calcifications) induration (in inflammatory carcinoma), 40 infection (infectious pathology), 20, 25, 26, 34 infiltration, neoplastic, 41 inflammatory polyarthritis (in relation to prostheses), 45 intracystic (see lesion) intracystic tumour, 29 intraductal (see calcification) invasive (see infiltrating carcinoma) involutional changes, 17 irregular (see calcifications)

163

N D E X

isodense (asymmetry), 20

L lactation, 17, 24 lesion/s, 18, 19, 23, 24, 26, 29-31, 33-36, 39-41, 43, 44 in the skin, 18 intracystic, 29 malignant, 36, 39, 41 multiple, 30, 36 non-palpable, 29, 36, 43 linear (see calcifications) lipoma, 14, 24 liponecrosis, 20, 23, 25 calcified, 23 cystic, 25 liposarcoma, 46 lobulate, lobulations (in nodule), 29, 33, 34, 46, 47 location of a lesion with hook wire, 36 low density (lesion of), 18, 34 low risk (in probably benign lesions), 29, 31 lupus erythematosus (in relation to prosthesis), 45 lymph node, 18, 43, 51 axillary, 18, 43 echographic characteristics, 18 intramammary, 18, 43, 50, 51 lymphatic obstruction, 41 lymphoma, primary lymphoma, 18, 41, 45-47

M magnetic resonance (in prostheses), 45 mammographic atlas, 7, 14 report, 13 report negative in breast cancer, 18 mammography, 13, 17-20, 24-26, 31, 34-36, 40, 41, 44-47, 49-52 mass associated (with structural alteration), 35 mastectomy, 44, 46 mastitis, 23, 25, 26, 41 mastitis of plasmatic cells, 23, 25 medio-lateral-oblique (MLO), 40, 44, 45, 49, 50 medullary (see carcinoma) melanoma (metastasis of), 47 menstruation, 17 metal particles (foreign as body), 44 metallic or barium markers for identifying dermic lesion, 19 metastasis axillar, 18 to the breast, 46 microcalcifications (see calcifications) microcysts, microcystic (see calcifications) microlobulated (see contour) miscellaneous, 43 MLO (see medio-lateral-oblique) mucin (in relation to microlobulated contours), 34

164

I multicentral, multifocal, 36

N D E X

N needle (see biopsy) neurofibroma, 19 nevus, 19, 51 nodule, nodule/mass in benign category, 24 in malignant category, 39 in normal category, 18 in probably benign category, 29 in probably malignant category, 33 lobulated, 34 multiple, 18, 26, 31 of fatty density, 24 of mixed density, 18, 24 of water density, 24 oval, 29 polylobulated, 33 round, 29 norm, normality (breast), 14, 20 normal dense (breast), 17 fatty (breast), 17

O obstruction of the subclavian vein or superior vein cava (cause of vascular asymmetry), 20 oedema, 26 oedema-thickened skin syndrome, 26 oily cyst, 24 ointments (as cause of pseudocalcifications), 43 orange skin syndrome (see peau dorange) oval (see calcifications)

P Pagets disease, 41 palpation, palpable (lesions, findings in), 13, 24, 26, 29-31, 34, 36, 40, 43, 44, 46, 52 papillary (see carcinoma) paraffin (in prostheses, injection of), 44 parenchyma (mammary), 20, 43, 45 peau dorange syndrome, 40 pectoral muscle (see retraction of) pencil point (as foreign body), 43 periductal (see calcifications) phyllodes tumour, 46 physician, 49, 52 physiological serum (in prostheses), 44 pleomorphic (see calcifications) polylobulated (see nodule) polymorphic (see calcifications) polyurethane (prosthesis capsule of), 44

165

N D E X

positive predictive value (PPV), 24, 29, 31, 33 postinfectious (see changes) postmastectomy reconstruction, 44 postmenopausial (see changes) postoperative (see changes) postoperative scar, 26, 35, 40 post-traumatic (see changes) potassium hydroxide (artefact by), 43 powder (artefacts by), 43 dermic, 19 hygiene, 19 talcum, 43 PPV (see positive predictive value) pregnancy, 17, 46 probability, 13, 33 programme (screening), 7, 13, 14, 33, 39, 49, 52 projectils (as foreign body), 43 projections (mammographic), additional, 14, 23 CC (see craniocaudal) complementary, 30 double, 34 focalised, 19, 20 lateral, 24, 25 magnified, 19, 20, 25, 29, 35 MLO (see medio-lateral-oblique) tangential, 19, 20 prolactin (and galactocele), 24 prostheses, 44, 45 protocol, 13, 17, 41, 49 pseudocapsule (in hamartoma), 24 pseudolymphoma, 41 pseudonodule, 20 pseudostar, 19 punctiform, punctata (see calcifications)

R radial scar, 25, 34, 40 radiolucent, 19, 20, 24 halo in dermic lesion, 19 radiotherapy, 25, 26, 41, 46 radiotransparent (see prostheses) ramified (see calcifications) reading protocol, mammography, 13, 17 reading system (mammographic), 7, 13, 14, 29, 30, 52 reductive (mammoplasty, surgery), 20, 40, 43 reference hospital, 23, 36, 41 retraction, cutaneous, 21, 36 of the nipple, 39, 40 of the pectoral muscle, 39, 41 retroaerolar (see areolar) rheumatoid arthritis, 43, 45 round (see calcifications)

166

I S sarcoma of soft parts (metastasis of), 47 sarcoma of the breast, 46 scars, 21, 25, 26, 43 sclerosing ductal hyperplasia, 25 screening interval, 23, 29 sebaceous gland (calcification), 19 sensitivity of the mammography, 17, 50 short term follow-up (mammographic), 14, 23, 24, 31, 52 sign of tattoo (in dermic calcifications), 19 silicone (in prostheses), 44 silicone injection (in prostheses), 44 Sjegrens syndrome (in relation to prostheses), 45 soaps (artefacts by), 43 sodium hydroxide (artefact by), 43 soya oil (prostheses), 44 spherical (see calcifications) spiculation, 33, 34, 39, 46 spot-film (see focalised projection) stability (of lesions), 35 star lesion (see stellate) stellate (nodule, image), 39, 40 stereotaxy (biopsy by), 36 structural alteration in the benign category, 24, 25 in the malignant category, 40 in the normal category, 19 in the probably malignant category, 34, 35 superimposing, 19, 29, 33 surgery, 20, 25, 40, 41, 43-45 surgical biopsy, 29, 31, 36 surgical specimen, 44 suture, 20, 25, 43

N D E X

T tangential (see projections) tattoo (see sign of and artefacts by) tattoo marks (simulating microcalcifications), 43 telorrhagia, 41 thickening of the nipple-areola, 41 of the pectoral, 39 traumatism (mammary), 20, 21, 25, 26, 40 triglyceride (in prostheses), 44 tubular (image), 30 tubular (see calcifications) tumoral, 35, 39, 40 tumorectomy, 20

167

N D E X

U ulcer by Efudix, 43 ultrasound, 13, 14, 18, 23, 24, 26, 29, 31, 34, 36, 46, 47, 49, 52 upper outer quadrant (UOQ), 18, 20, 26, 30

V Valencia Breast Cancer Screening Programme (VBCSP), 14, 24, 29, 31, 34 vascular (see calcifications) vermicular (see calcifications) volumetric (effect, asymmetry), 20, 33

W warts, 18, 19, 51 worksheet, 57

Z zinc oxide (artefact by), 43

168

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D E

S A N I TAT

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