Approach to mammogram

1. Approach to mammogram

2. General breast anatomy • Conical, round or hemispherical shape • Comprised of 15-20 lobes, each encased in fascial sheath defined by AMF & PMF • Extends from 2nd or 3rd intercostal space to 6th or 7th intercostal space • Extends laterally to anterior axillary fold and medially to lateral sternum • Relationship to chest wall • Superior two-thirds overlies pectoralis major muscle • Lateral portions overly serratus anterior muscle • Inferior-most margin overlies upper abdominaloblique muscles • Axillary tail of Spence: Extension of normal breast • tissue toward axilla

3. ZONAL ANATOMY • Premammary (Subcutaneous) Zone • Most superficial zone • Anterior margin defined by skin, posterior margin defined by AMF • Contains subcutaneous fat, blood vessels, anteriorsuspensory (Cooper) ligaments • May contain ectopic ducts and TDLUs ASLs(Cooper ligaments) • Formed from two leaflets of AMF inserting into dermis • Provide support for breast • Usually visible on mammograms and sonograms

4. • Mammary Zone • Defined anteriorly by AMF and posteriorly by PMF • Contains majority of ducts/TDLUs, stromal fat and stromal connective tissue • Subdivided haphazardly by interspersed ASLs. • Retromammary Zone • Most posterior of three zones • Defined anteriorly by PMF and posteriorly by chest wall • Contains fat and PSLs which attach PMF to chest wall

5. BI-RADS BREAST COMPOSITION • The American College of Radiology Breast Imaging and Reporting Database System (BIRADS)divides breast composition into four categories: • 1) almost entirely fat, • 2) scattered fibroglandular densities (approximately 25-50% glandular), • 3) heterogeneously dense (51-75% glandular), • 4) extremely dense (greater than 75% glandular).

6. BIRADS INFERENCE 0 Needs additional imaging evaluation 1 2 RISK OF MALIG. Negative/ Normal Benign Findings. •Fat containing. •Benign Intramammary LN •Benign Calcifications No further evaluation needed 3 Probably Benign. Short term Follow up is suggested TYPICAL EXAMPLES =< 2 % Round, oval or lobulated lesion with circumscribed margins.

7. 4 Suspicious Abnormality. 3 – 94 % Biopsy should be considered 5 6 Highly suggestive of malignancy Appropriate intervention to be taken Biopsy proven Malignancy > 95% Irregular shaped, spiculated margins.

8. MASS CALCIFICATION ASYMMETRIC BREAST FINDINGS INTRAMAMMARY TUBULAR DENSITY ARCHITECTURAL DISTORTION LYMPHNODE OTHER ASSOCIATED FINDINGS

10. SOL seen in two different projections and have convex borders. 1. SIZE 2. SHAPE 3. MARGINS 4. DENSITY 5. CALCIFICATION

11. SHAPE

12. MARGINS

13. DENSITY  High  Iso  Low ( not fat)  Fat containing  Oil cysts  Lipoma  Galactocele  Hamartomas  Fibroadenolipomas

14. MASS CALCIFICATION ASYMMETRIC BREAST FINDINGS INTRAMAMMARY TUBULAR DENSITY ARCHITECTURAL DISTORTION LYMPH NODE OTHER ASSOCIATED FINDINGS

15. Morphology Distribution Number Size

16. MORPHOLOGY BENIGN INTERMEDIATE CONCERN OR SUSPICIOUS CALCIFICATION HIGH PROBABILITY OF MALIGNANCY

17. MORPHOLOGY: Benign Skin Calcification Vascular Calcification Popcorn Calcification Rod like Calcification Lucent Centered Deposits Eggshell/ Rim Calcification Precipitated Calcification in milk of calcium. Large Dystrophic Calcification

18. Skin Calcification Tattoo Sign Usually located along inframammary fold parasternally, axilla and areola. Can be seen in the skin which is enface

19. Vascular Calcification Linear or parallel tracks that are usually clearly associated with blood vessels.

20. Popcorn Calcification Involuting Fibroadenoma

21. Rod like calcification Within ectatic ducts due to secretory deposits and follow ductal distribution radiating towards nipple. May be continuous or discontinuous and may show branching. Differentiate from malignant fine branching calcifications.

22. Lucent centered deposits Fat Necrosis Calcified Debris in ducts Occasionally in Fibroadenoms

23. Eggshell or Rim Calcification Wall of the Cyst. Fat Necrosis. Periphery of Fibroadenoma

24. Milk of Calcium Are benign sedimented calcification in macro or micro cysts. Typical feature is apparent change in shape on different projections.

25. • Whenever there is possibility of milk of calcium consider magnification medio-lateral spot film

26. Dystrophic Calcification Coarse irregular lava shaped calcification. In irradiated breast or following trauma

27. Round calcification >0.5 mm. In fibrocystic changes or adenosis or skin calcification.

28. MORPHOLOGY: Intermediate Concern RISK OF MALIGNANCY

29. Amorphous or indistict calcification  Calcification without a clearly defined shape or form. They are usually so small or hazy in appearance, that a more specific morphologic classification can not be determined.  Present in many benign and malignant breast diseases. About 20% of amorphous calcifications turns out to be malignant.

30. Coarse Heterogenous Irregular calcification that are usually larger than 0.5 mm but not the size of large heterogenous dystrophic calcifications.

31. MORPHOLOGY: High Probability of Malignancy Fine Pleomorphic: < 0.5 mm Variable in size, density or form 25 – 40% risk of malignancy

32. Fine Linear or Branching < 0.5mm in width. Linear or branching distribution

33. • As compared to Malignant Calcification, Benign Calcifications are: – Larger – Coarser – Round and smooth – Easily seen.

35. • In contrast to a mass, which is a 3-D structure demonstrating convex outward borders and which is usually evident on two orthogonal views, asymmetric findings lack the convex outward borders and the conspicuity typical of a mass.

36. ASYMMETRIC BREAST FINDINGS ASYMMETRY GLOBAL ASYMMETRY FOCAL ASYMMETRY

37. ASYMMETRY • If a potential mass is seen in only a single view at standard mammography, it should be called an “asymmetry” until its three-dimensionality is confirmed. • Approximately 80% of cases are due to summation shadow, of normal fibroglandular breast. • True lesions may sometimes appear on only one view because on other views they are either obscured by overlapping dense parenchyma or are located outside the field of view.

38. GLOBAL ASYMMETRY • Is seen in both the views. • Involves a greater volume of breast tissue (at least a quadrant) • Without any associated mass, suspicious calcifications, or architectural distortions. • It is usually due to normal variations or hormonal influence and only significant when it corresponds to a palpable abnormality.

39. FOCAL ASYMMETRY • Is seen in both the views. • Involves a less than one quadrant of breast. • It can be due to normal variations or some lesion.

40. DEVELOPING ASYMMETRY • This is a focal asymmetry that is new, larger, or denser at current examination than at previous examinations.

41. ASYMMETRY BIRADS I DEVELOPING ASYMMETRY BIRADS IV NONPALPABLE NONPALPABLE PALPABLE PALPABLE GLOBAL ASYMMETRY FOCAL ASYMMETRY GLOBAL ASYMMETRY FOCAL ASYMMETRY BIRADS II BIRADS III BIRADS IV BIRADS IV

43. BENIGN INTRAMAMMARY LYMPH NODE • Well circumscribed. • < 1cm • UPPER AND OUTER QUADRANT • Lucent and invaginated fatty hilum • May appear as 3 or more round densities in horse shoe arrangement.

44. When not to consider Benign Intramammary node • If a mass is seen in a section other than upper and outer quadrant, unless it has a clearly defined hilum. • Lesion in upper outer quadrant does not have other characteristics, it should be considered suspicious as malignant node or primary mass.

46. • Tubular or branching structure representing dilated duct. • Usually of minor significance. • BIRADS III

48. • Spiculations radiating from a point without any identifiable mass. • The only architectural distortion that does not require further evaluation is that caused by prior surgery or trauma. • BIRADS IV

49.  SKIN RETRACTION  NIPPLE RETRACTION  SKIN THICKENING  TRABECULAR THICKENING  AXILLARY LYMPHADENOPATHY

50. • FINALLY WE HAVE to decide on the significance of the mammographic findings. • FINALISE THE REPORT IN 7 SPECIFIC CATEGORIES.

Approach to mammogram

Arif S

Approach to mammogram