20° oblique projection is a troubleshooting projection used in mammography, especially in young women and in follow-up patients.
The C-arm is turned approximately 20° for a superomedial-inferolateral oblique. With the patient's feet pointing towards the unit and her torso turned slig...
The 5-tier ACR system was a previously used system for classification of radiologic breast findings, proposed by the American College of Radiologists (ACR). It is no longer in widespread use, having been gradually superseded by the new 6-tier BIRADS classification system first published in 1992....
Aberrations in the Normal Development and Involution of the breast (ANDI) is an all-encompassing term that is used to describe a wide spectrum of the benign breast diseases. As the name suggests, it is based on the theory that most of the encountered benign breast disorders are essentially minor...
Abscesses are focal confined collections of suppurative inflammatory material and can be thought of as having three components 1:
a central core consisting of necrotic inflammatory cells and local tissue
peripheral halo of viable neutrophils
surrounded by a 'capsule' with dilated blood vessel...
Accessory breast tissue is a relatively common congenital condition in which abnormal accessory breast tissue is seen in addition to the presence of normal breast tissue. This normal variant can present as a mass anywhere along the course of the embryologic mammary streak (axilla to the inguinal...
Adenoid cystic carcinomas are a rare histological subtype of adenocarcinoma.
Adenoid cystic carcinomas are generally considered low grade 4. The tumours have a notable tendency for perineural spread.
They have a wide distribution and mainly occur in relation to the airways...
Adenoid cystic carcinoma (ACC) of the breast is a rare subtype of breast cancer.
They account for only 0.1-0.4% of all breast cancers.
The tumour demonstrates a strikingly characteristic microscopic pattern similar to that of adenoid cystic carcinoma of the salivary gl...
Adenomatous breast lesions are benign tumors which grow from glandular parenchyma. The breast is a conglomeration of various glandular tissues, hence they can be of several types.
apocrine adenoma of breast
pleomorphic adenoma of breast
Adenosis of the breast is a benign lobulocentric proliferative process in which lobules are enlarged and increased in number in addition to an increased number of glands within each lobule.
Pathologically subclassified into three main subtypes which include:
sclerosing adenosis of the breast
Albert Salomon (1883-1976) was the first physician to study x-rays of breast tissue.
Development of mammography
Salomon worked at the Royal Surgical University Clinic in Berlin and from about 1913 x-rayed 3000 breast specimens obtained from the morgue in an attempt to identify breast patholog...
Mammographic screening detects early breast cancers and thereby reduces potential mortality. However, its sensitivity is inversely related to breast density 1.
Altered density between two mammograms can arise in a number of situations:
Affecting both breasts:
interval commencement/cessation ...
Amastia is a rare congenital condition characterised by the absence of breast tissue, nipple and areola. This may occur unilaterally or bilaterally.
During embryological development, breasts first appear as ectoderm ridges during the 6th week of gestation. This ridge grows thicker an...
Amazia is a rare congenital condition defined by the absence of glandular parenchyma in either one or both of the breasts and a normal nipple and areola complex.
This is a very rare entity and the true prevalence is not known. Although there are strict definition criteria, the di...
Amorphous or indistinct calcifications are a morphological descriptive term for breast calcification and are defined as having small, hazy, faint calcifications with no clearly defined shape or form.
80-200 micrometer in diameter
small, hazy calcification
The anatomy curriculum is one of our curriculum articles and aims to be a collection of articles that represent the core anatomy knowledge for radiologists and imaging specialists.
Head and neck anatomy
Abdominal and pelvic anatomy
Breast angiosarcomas are a rare vascular breast malignancy.
As primary tumours of the breast, they account for ~0.04% 2 of all breast cancers and tend to occur in younger women, in their 3rd to 4th decades. Secondary angiosarcoma has an estimated incidence of ~0.09-0.16% and occur...
Apocrine carcinoma of the breast is a rare variant of breast cancer. The diagnosis is mainly pathological as it is difficult to differentiate from other forms of breast cancer on imaging.
It accounts for about 4% of all cases. It is seen most often in females in the age group of 5...
Apocrine metaplasia of the breast is a benign breast condition and is sometimes considered part of or associated with fibrocystic change. It is a common finding in the female breast, particularly after the age of 25, and many regard it as a normal component of the breast.
Architectural distortion is a mammographic descriptive term in breast imaging. It may be visualised as tethering or indentation of breast tissue.
Architectural distortion per se is not a mass. It is often due to a desmoplastic reaction in which there is focal disruption of the normal...
Artifacts that mimic breast calcification can arise from a number of sources. These include:
deodorants on skin: most practices recommend that clients for mammography do not use deodorant or perfume on the day of the study for this reason. The residue from deodorant is a very fine, dense, misty...
Asymmetrical mammographic density is a mammographic morphological descriptor. It is given when there is increased density in one of the breasts, on either one or both standard mammographic views but without evidence of a discrete mass. An asymmetrical density can be further characterised as:
Asymmetry in breast size can arise from a number of factors.
Breasts are rarely absolutely the same size or volume. Normal variation is common. Most females have slight discrepancies in breast size. Asymmetric progressive breast enlargement is unusual but known. The role of the breas...
Atypical ductal hyperplasia (ADH) is a histologically borderline lesion that has some, but not all the features of ductal carcinoma in situ (DCIS). Sometimes the distinction between ADH and DCIS is simply on the basis of the number of ducts involved.
Atypical ductal hyperplasia is a...
Atypical lobular hyperplasia (ALH) is a pre-malignant lesion of the breast which falls at the milder end of the spectrum of lobular neoplasia. It is therefore considered a part of borderline breast disease.
It is usually asymptomatic and mammographically occult and is in...
An automatic full-field volumetric breast ultrasound scanner (AFFBUS) is a developing technology which was initiated to overcome the drawback of dense breast and to get a three-dimensional view of the breast.
Automatic ultrasound imaging ac...
Axillary lymph nodes (LN) are in the axilla and receive lymph from vessels that drain the arm, the walls of the thorax, the breast and the upper walls of the abdomen.
There are five axillary lymph node groups, namely the lateral (humeral), anterior (pectoral), posterior (subscapu...
An axillary view (also known as a "Cleopatra view“) is a type of supplementary mammographic view. It is an exaggerated craniocaudal view for better imaging of the lateral portion of the breast to the axillary tail. This projection is performed whenever we want to show a lesion seen only in the a...
Balloon breast brachytherapy (BBB) is a technique for delivering radiation treatment in women with early stage breast cancer. It is given after lumpectomy, or surgical removal of a small breast neoplasm, and is a shorter alternative to the more traditional method of external beam radiation for s...
Benign and malignant characteristics of breast lesions at ultrasound allow the classification as either malignant, intermediate or benign based on work published by Stavros et al. in 1995.
Malignant characteristics (with positive predictive values)
Bilateral axillary lymphadenopathy can result from a number of causes and generally implies a systemic process. They include:
autoimmune diseases, e.g.:
systemic lupus erythematosus (SLE)
BIRADS 0 category is one of six from the breast imaging reporting and data system and is used when imaging is incomplete such as:
when further imaging or information is required, e.g. compression, magnification, special mammographic views, ultrasound
when requesting previous images not availab...
A BIRADS I category under the breast imaging reporting and data system is when no finding is present in an imaging modality (not even a benign finding).
BI-RADS II is a benign category in the breast imaging reporting and data system. A finding placed in this category should have essentially a 100% chance of being benign.
Examples of such lesions include:
multiple secretory calcifications
fat-containing lesions such a...
BIRADS III is an intermediate category in the breast imaging reporting and data system. While it is usually classified as benign or probably benign, a finding placed in this category should have a very high probability of being benign. The risk of malignancy in a BIRADS III lesion is considered ...
A BIRADS IV lesion under the breast imaging reporting and data system refers to a suspicious abnormality. BIRADS IV lesions may not have the characteristic morphology of breast cancer but have a definite probability of being malignant. A biopsy is recommended for these lesions. If possible, the ...
BIRADS V lesions under the BIRADS (breast imaging reporting and data system) refer to breast lesions that are highly suspicious for malignancy, requiring appropriate action to be taken (i.e. biopsy and management as appropriate). BIRADS V lesions have the characteristic morphology of breast canc...
BIRADS VI is a new addition to the ACR (American College of Radiology) BIRAD system. The prior classification system was a 5 tier system. The current system is a 6 tier system.
According to the current BIRADS tier, patients with biopsy proven cancer prior to definitive therapy would be category...
Borderline breast disease (BBD) refers to a group of conditions while being not completely malignant are still concerning. Usually an excision biopsy is recommended if entities falling into borderline breast disease is detected on core biopsy.
These entities include:
atypical ductal hyperplasi...
Brachytherapy, also known as sealed source radiotherapy or endocurietherapy, is a form of radiotherapy where a radioactive source is placed, under the guidance of imaging, within or next to the area requiring treatment.
Brachytherapy is commonly used to treat localised prostate cancer, breast c...
The breast is an apocrine gland seen in both males and females. However, in females it has a specific function which is the production of milk.
The breast has an inhomogeneous structure which is predominantly composed of adipose tissue and glandular tissue. In additi...
A breast abscess is a relatively rare but significant complication of mastitis that may occur during breastfeeding, particularly in primiparous women. The clinical context is a key to diagnosis as imaging appearances (particularly ultrasound) can mimic many other entities such as breast carcinom...
Amyloid deposition in the breast is predominantly of two forms
breast involvement in primary amyloidosis - commoner
in association with other conditions like multiple myeloma, plasmacytosis and rheumatoid arthritis and another in the localised form which is rarer.
Breast aneurysms are a rarely seen cause of a breast mass.
true aneurysm: occurs post trauma and is seen as a slowly enlarging pulsatile mass
false aneurysm / pseudoaneurysm: occurs in acute trauma, post percutaneous biopsy, due to spontaneous haemorrhage secondary to coagulo...
Breast calcifications can arise from a vast number of aetiologies.
They are extremely common and can be present in ~85% of mammograms 8. Their frequency increases with age. Up to 50% of breast cancers can be associated with calcification while 15-30% of calcifications biopsied fo...
Breast calcifications are relatively frequently found on mammograms and are indicative of focally active process, however about 80% of these processes are benign. Thus the ability to distinguish these calcifications based on their morphological characteristics, size, number and distribution is i...
Metastases from breast cancer can be a frequent finding in routine onco-radiological practice.
With the universal use and acceptance of screening mammography, the isolated clinical presentation from metastases from breast carcinoma have become rare in clinical practice. H...
Breast cancer staging uses the TNM staging system and then into stage groupings.
Primary tumour (T)
Tx: primary tumour cannot be assessed
T0: no evidence of primary tumour
Tis: carcinoma in situ
T1a: 0.1-0.5 cm
T1b: 0.5-1.0 cm
T1c: 1.0- 2.0 cm
T2: 2-5 cm
Breast cancer is the commonest malignancy in female patients.
This is a summary article; read more in our article on breast cancer.
change in breast shape or skin
axillary lymph node enlargement or breathl...
Breast cellulitis is an acute pyogenic inflammatory change involving the dermis and subcutaneous tissue. This can be secondary to any wound, surgery or radiation for breast carcinoma.
inflammatory changes such as oedema, swelling and redness of the involved breast
The percutaneous breast biopsy is one of the current choices for focal histopathological assessment of breast lesions. In contrast to fine needle aspiration, during a core needle biopsy, a hollow needle is used to withdraw small cores of tissue from the area of interest in the breast.
The breast curriculum is one of our curriculum articles and aims to be a collection of articles that represent core breast knowledge.
Topics pertaining to the breast.
An understanding of the anatomy of relevant structures is essential. Core anatomical topics include:
Breast cysts are a common mammographic and sonographic finding, and can be of different types:
simple breast cyst: typically is a well-defined, anechoic lesion with imperceptible wall and posterior acoustic enhancement 1
complicated breast cyst: contains intracystic echoes or debris with other...
Breast density on mammography can significantly vary between individuals. The density is a function of the relationship between radiolucent fat and radiodense glandular tissue.
Breast density varies with age and generally younger women have denser breasts (i.e. more glandular tissue relative to...
Breast ductography (a.k.a. galactography) is an imaging technique which is used to evaluate lesions causing nipple discharge. It helps in precisely locating the mass within breast tissue and gives useful information for surgical approach and planning.
A blunt-tipped sialogram needle ...
Breast echotexture according to the BI-RADS lexicon is usually classified into three categories 1:
Breast haematoma can result from preceding direct trauma, surgery, biopsy (rare) or contusion and can be easily misinterpreted as other lesions such has breast malignancy if the correct clinical context is not taken into account. They can rarely occur spontaneously, especially in those with coag...
Breast hamartoma (also known as a fibroadenolipoma) is a benign breast lesion.
They typically occur in women older than 35 years of age.
While it can present as a painless soft lump, it may also present as unilateral breast enlargement without a palpable l...
Breast hypoplasia is a condition which is characterised by underdevelopment of the breast. Breast hypoplasia can be congenital or acquired.
congenital adrenal hyperplasia
Breast screening and diagnostic programmes cannot exist without the technologists. They play an indispensable role in the acquisition of mammogram and ultrasound images in both screening and diagnostic settings.
The mammogram technologist: the primary responsibility of the "mammo tech" is the ...
BI-RADS classification is proposed by American College of Radiology, last updated in November 2015, and is widely used classification system at the time of writing this article (July 2016).
The BI-RADS acronym stands for Breast Imaging-Reporting and Data System which is a widely accepted risk a...
Breast implant ruptures are a recognised complication of a breast implant. It can be intracapsular, when confined by the surrounding fibrous capsule, or extracapsular, when silicone freely extravasates.
After implantation of a silicone or saline breast implant, a fibrous capsule (sc...
Breast implants are increasingly common in general breast radiology practice.
Breast implants may be placed behind the glandular tissue but in front of the pectoral muscle:
The second position of breast impla...
A mnemonic to help remember breast lesion localisation when given a set of mammograms (MLO and CC) is:
muffins rise and lead falls
This can help localise the lesion into the quadrant (e.g. upper, outer) to make ultrasound correlation easier.
muffins rise: if the lesion is located me...
Breast lipomas are a benign breast lesion and is classified as a BIRADS II lesion.
Lipomas are mostly asymptomatic and coincidentally discovered on routine mammography. Patients may present with a painless palpable breast lump which is soft and mobile. In these cases the ...
Breast lumps have different characteristics that allow simplification of differential diagnosis by breaking down the vast list into sections. Consider whether the lump fits into one of these categories.
Spiculation is a feature of neoplasms and all masses that display spicula...
Breast lymphoma refers to involvement of the breast with lymphoma and may be primary or secondary.
Both primary and secondary breast lymphoma are rare accounting for ~ 0.5% (range 0.3-1.1%) of all breast malignancies.
Breast lymphoma may present either as a...
Breast MRI is the most sensitive method for detection of breast cancer. Depending on international health regulations, it is either applied for screening of women at high risk for developing breast cancer (e.g. BRCA1 and BRCA2 carriers), as an additional diagnostic test in pretherapeutic breast ...
The breast MRI classification flowchart (or Tree algorithm) is an evidence-based clinical decision rule to distinguish benign from malignant lesions in breast MRI. It incorporates five diagnostic criteria that are mainly consistent with BI-RADS though assigning diagnostic weights.
Following administration of Gadolinium there can be three possible enhancement kinetic curves for a lesion on breast MRI (these are also applied in other organs such as prostate MRI). These are sometimes termed the Kuhl enhancement curves.
type I curve: progressive enhancement pattern
There are many types of breast neoplasms, which can be divided into the following broad oversimplified categories as a starting point.
intralobular (epithelial and stromal)
metastasis to breast
Intralobular and interlobular refer to the terminal duct lobular un...
Breast sarcoma refers to a relatively heterogenous group of rare breast tumours which can include:
angiosarcoma of the breast
pleomorphic sarcoma of the breast
fibrosarcoma of the breast
myxofibrosarcoma of the breast
leiomyosarcoma of the breast
primary osteosarcoma of the breast
The breast screening program is where mammography is carried out in asymptomatic women for the improved detection of breast cancer.
Each country/state has its own program and some are listed as below (accurate as of Dec 2010).
Australia: primarily targeted at women between 50-74 every two year...
Breast sebaceous cyst, also sometimes known as an epidermal inclusion cyst or simply epidermoid cyst, is a benign breast lesion (BIRADS II).
For a general discussion of this entity outside the breast, please refer to epidermal inclusion cysts.
The two terms, breast sebaceous cys...
Breast tissue markers are a common finding in breast radiology. These are typically inserted following percutaneous biopsy, either under ultrasound or sterotactic guidance. They can be invaluable in identifying known benign areas or shrinking/treated malignant lesions on follow up imaging.
Breast ultrasound is an important modality in breast imaging. It is the usual initial breast imaging modality in those under 30 years of age in many countries.
In assessing for malignancy, is important to remember that one must use most suspicious feature of 3 modalities (pathology, ultrasound,...
Breast varix is, as the name suggests, varices in the breast that are focally dilated veins in the breast.
If varices are seen bilaterally then a cause for central venous obstruction (superior vena cava syndrome) could be the underlying aetiology with the varices being a part of the...
Breast venous malformations (also known as breast haemangiomas) are benign vascular lesions occurring within breast tissue.
Most breast venous malformations are so called cavernous malformations, which are found throughout the body. For a general discussion please refer to the general article o...
The breast within a breast sign refers to the common mammographic appearance of breast hamartomas (fibroadenolipomas). Since these benign lesions are well-circumscribed and contain a mixture of fibrous, glandular and fatty tissue (just like normal breast), it is not surprising that they appear v...
The bullseye view is designed for better evaluation of lesion located in retroareolar area. In this view, the nipple-areola complex are directed upward or downward on the detector surface to visualize the areolar and periareolar region en face, allowing characterization of lesions in this area.
Calcific axillary lymphadenopathy is in general, more concerning than axillary lymphadenopathy alone and is particularly so if it contains microcalcifications. While this is concerning for malignancy, it can also occur from occasional nonmalignant causes
metastatic axillary lymp...
In mammography, the term calcific cluster is usually given to where at least five microcalcifications in one cubic centimetre (that is 1 square cm) on two projections on a non-magnified contact view 1.
Homogeneous, smooth clustered microcalcifications can be due to 2:
A simple mnemonic to recall a list of commonly calcifying metastases is:
B: breast cancer
T: papillary thyroid cancer
O: ovarian cancer (especially mucinous)
M: mucinous adenocarcinoma (especially colorectal carcinoma)
Capsular contractures are a potential complication of a breast implant and refers to a tightening and hardening of the capsule that surrounds a breast implant. It is a condition that can distort the shape and cause pain in the augmented breast. It seems to be the commonest complication post-brea...
Serum carcinoembryonic antigen (CEA) is a cell-adhesive glycoprotein that was discovered in colorectal cancer in 1965, and is hence one of the oldest and most used tumour markers. Its name derives from its normal expression in fetoembryonic liver, gut and pancreas tissue.
Normal range of CEA is...
Caudal cranial projection is an additional trouble shooting view.
invert the C arm as for a CC projection
step the patient forward and have her bend excessively forward at the waist to ensure that the abdomen does not encroach in the x ray field
place the image receptor above the b...
The causes of breast oedema can be remembered using the mnemonic:
V: venous obstruction
I: inflammatory breast cancer
L: lymphatic obstruction
S: surgery (recent)
Cavernous venous malformation, also traditionally referred to as a cavernous haemangioma (despite it not being a tumour) or cavernomas, are non-neoplastic slow flow venous malformations found in many parts of the body.
Despite the ubiquity of use of the traditional terms cavernoma...
Chassaignac bursa (also known as retromammary bursa or submammary serous bursa) is the space behind the breast.
It contains loose connective tissue and aids in mobility of the breast on the thoracic wall. Posteriorly it is bound by the pectoral fascia and anteriorly by the deep layer of the su...
The new pathological classification of DCIS is based on cytonuclear atypia, degree of necrosis, size, and distance from margin/architecture. Low and intermediate grades DCIS require cytologic, architectural and size criteria to be met but high-grade DCIS requires only cytologic criteria; this is...
A cleavage view (also called "valley view") is a mammogram view that depict the posteromedial portion of both breasts (the “valley” between the two breasts) by placing them on the cassette at the same time and pulling them anteriorly.
Manual technical factors should be used.
A cleavage view m...
Coarse macrocalcifications within the breast are a morphological descriptive term for a type of breast calcification.
involuting fibroadenomas ( classical popcorn calcification )
chronic renal disease with hypercalcaemia 1
rarely seen in malignancy 2
invasive breast carci...
Columnar alteration with prominent apical snouts and secretions (CAPSS) is a pathological entity encountered when breast biopsies are done for investigation of punctate or amorphous calcifications. CAPSS involves the terminal ductal and lobular units (TDLU's).
It is sometimes classified under t...
Columnar cell lesions of the breast comprise of a wide-range of breast lesions which are commonly characterised by columnar cells lining the terminal ductal and lobular unit. These range from those that show little or no cytologic or architectural atypia to those that show sufficient cytologic a...