Атлас маммографии (англ.)

Teaching Atlas
of Mammography
László Tabár, MD
Professor
Department of Mammography
Central Hospital, Falun, Sweden
University of Uppsala
School of Medicine
Uppsala, Sweden
Peter B. Dean, MD
Professor
Department of Diagnostic Radiology
University of Turku
Director of Breast Imaging
Turku University Hospital
Turku, Finland
With the contribution of
Tibor Tot, MD, PhD
Associate Professor of Pathology
and Chairman
Department of Pathology
and Clinical Cytology
Central Hospital
Falun, Sweden
4th edition
669 illustrations
Thieme
Stuttgart · New York
IV
Library of Congress Cataloging-in-Publication Data is available from
the publisher.
1st English edition 1983
2nd English edition 1985
1st German edition 1985
1st Spanish edition 1985
1st Italian edition 1986
1st Portuguese edition 1994
3rd English edition 2001
2nd Italian edition 2002
1st French edition 2002
2nd Spanish edition 2002
2nd Portuguese edition 2002
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ISBN 978-3-13-640804-9
123456
V
Preface to the Second Edition
This atlas consists of a systematic collection of mammograms of
breast lesions, many in the early and some in the earliest detectable
phases of development. These reflect the types of lesions to be found
in a mammography screening population. Small malignant lesions
are presumed to be the precursors of large, metastasizing lesions,
and their removal at a sufficiently early stage should prevent the
development of breast cancer to the stage where it kills the patient.
There is no question that mammography screening, when performed to high standards and repeated at sufficiently frequent
intervals, leads to the detection of most breast cancers at a preclinical stage. The result is a lower mortality from breast cancer and, in
many cases, less mutilating and traumatic therapy than previously
possible.
This book was written to help radiologists fill the anticipated
need for many skilled mammographers. We expect that this need
will continue to grow as population screening with mammography
becomes more widely adopted.
This edition contains no major revisions and no additional figures. We are grateful to many of our colleagues for constructive
criticism, and with the publication of this second edition we have
endeavored to respond to their comments.
László Tabár, Falun, Sweden
Peter B. Dean, Turku, Finland
Preface to the Third Edition
The passage of time has provided the opportunity for adding a longterm follow-up for those women who were diagnosed with breast
cancer two decades ago and whose mammograms are included in
this edition. Several cases have been replaced to emphasize important teaching points.
Our understanding of the variations in normal and pathological
breast anatomy as represented on the mammogram has increased
greatly during the intervening years, thanks largely to knowledge
gained from the analysis of thick-section, three-dimensional histology. There have also been a few changes in nomenclature, which
have been introduced to this edition. The authors have also drawn
upon fifteen years further experience in teaching breast imaging
when revising the text. These factors in combination will explain to
the reader why so much of the text to this book has been rewritten
for this edition.
Close cooperation with a skilled pathologist is essential if a radiologist is to learn from his/her own patients. We are pleased to
acknowledge the contribution of Tibor Tot, MD, who has provided
us with the histopathological images.
László Tabár, Falun, Sweden
Peter B. Dean, Turku, Finland
VI
Preface to the Fourth Edition
The conversion to digital mammography, a dramatic improvement
in breast ultrasonography, and the ascendance of breast magnetic
resonance imaging (MRI) during the past decade serve to confirm
the need for radiologists to be fully conversant with the radiologic
anatomy of the normal breast and its distortion by benign and
malignant breast lesions. All these major improvements in imaging
bring us ever closer to the actual subgross (3 D) image of the breast
tissue.
The subgross, thick-section histologic images of normal and
pathologic breast tissue serve as an intermediary between the
imperfect resolution of any imaging method and the cellular details
seen under the microscope. Furthermore, studying these subgross
images assists in comprehending the pathophysiologic processes
leading to specific changes in the breast tissue. Breast imagers
who are familiar with these alterations at the subgross level will
have a great advantage in the interpretation of breast images, regardless of the methodology used.
As breast-imaging methodology improves by quantum leaps, and
as breast imagers become more knowledgeable from studying subgross histology images correlated directly with the imaging methods, the preoperative diagnoses will become ever more accurate,
smaller tumors will be detected more reliably, the full extent of the
disease will be more precisely described, particularly with multifocal and diffuse breast cancers, and patient management can be
more fully individualized.
These advancements serve all women, who first and foremost
want to be assured that they do not have breast cancer. For those
who develop the disease, early detection and accurate diagnosis will
ensure the best achievable long-term outcome, while in many cases
less radical, custom-tailored treatment will minimize the side effects of therapy.
Long-term (25–30 years) follow-up of breast cancer screening
trials continues to confirm the benefits of early diagnosis and complete surgical removal of breast cancer, which continue to improve
with follow-up time, while many purported ”harms” fade away. The
significant improvement in the spectrum of tumor characteristics
obliges health-care professionals involved in the diagnosis and
treatment of breast cancer patients to re-evaluate their diagnostic
and therapeutic approaches to the disease. We have revised this
Atlas with these thoughts in mind.
László Tabár, Falun, Sweden
Peter B. Dean, Turku, Finland
VII
Introduction
The purpose of this Atlas is to teach radiologists how to analyze
mammograms and arrive at the correct diagnosis through proper
evaluation of the findings. The illustrated cases cover practically the
entire spectrum of breast abnormalities. They are based upon referred patient material as well as upon a large number of mammographic screening examinations. This edition includes the outcome
of screen-detected cases followed for up to 25 years.
There are two basic steps in the interpretation of mammograms:
perception and analysis.
Since the greatest benefit of mammography lies in the detection
of breast carcinoma in its earliest possible stages, every mammogram must be systematically surveyed for the subtle hints of malignancy. Perception is taught in this Atlas by describing a method for
systematic viewing (Chapter 2). The reader is then provided with a
series of mammograms, many with obscure lesions, to encourage
practice with this method. With the help of a coordinate system, the
lesions can be precisely located. Practice in perception continues
throughout the Atlas. After detecting an abnormality on the mammogram, the diagnosis can be reached through a careful analysis of
the mammographic tumor features. Additional projections, coneddown compression, and microfocus magnification views are necessary for the analytic workup, prior to the use of other imaging tools.
Rather than starting with the diagnosis and demonstrating typical findings, the approach of this Atlas is to teach the reader how to
analyze the image and reach the correct diagnosis through proper
evaluation of the mammographic signs. Prerequisites for the perception and evaluation of the mammographic findings are optimum
technique, knowledge of anatomy, and understanding of the pathological processes leading to the mammographic appearances.
Breast lesions are extremely heterogeneous. It is an oversimplification to expect that one single imaging method can image all
breast disease subtypes with equal proficiency.
Consequently, ancillary imaging and interventional methods
have been developed during the past few decades to increase the
sensitivity and diagnostic accuracy of breast imaging. The proliferation and refinement of these methods has not decreased the importance of a thorough mammographic workup. On the contrary, a
careful analysis of the subtle mammographic signs will help the
radiologist choose the ancillary imaging and interventional method(s) best suited for reaching an accurate diagnosis and describing
the true extent of the disease.
VIII
Contents
I
Anatomy of the Breast . . . . . . . . . . . . . . . . . . . . . .
1
II
Method for Systematic Viewing of Mammograms . . .
5
III
Approach to Viewing Mammographic Images and
Interpreting the Findings . . . . . . . . . . . . . . . . . . . .
15
IV
V
VI
Circular/Oval Lesions . . . . . . . . . . . . . . . . . . . . . . .
Signs of Primary Importance in Diagnosing
Circular/Oval Lesions . . . . . . . . . . . . . . . . . . . . . . . .
Signs of Secondary Importance in Diagnosing
Circular/Oval Lesions . . . . . . . . . . . . . . . . . . . . . . . .
Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Practice in Analyzing Circular/Oval Tumors (Cases 1–56)
Stellate/Spiculated Lesions and Architectural
Distortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Practice in Analyzing Stellate/Spiculated Lesions and
Architectural Distortion on the Mammogram
(Cases 58–85) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Calcifications on the Mammogram. . . . . . . . . .
Malignant-Type Calcifications within Ducts and/or
in Terminal Ductal Lobular Units . . . . . . . . . . . . .
Practice in Calcification Analysis (Cases 86–109) . .
Benign-type Calcifications within Ducts or Lobules
Miscellaneous Calcifications . . . . . . . . . . . . . . . .
Practice in Calcification Analysis (Cases 112–152) .
17
18
19
20
21
101
106
....
169
.
.
.
.
.
.
.
.
.
.
170
173
239
242
243
VII
Thickened Skin Syndrome of the Breast . . . . . . . . . .
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . .
Mammographic Appearance . . . . . . . . . . . . . . . . . . .
289
291
291
VIII
Overall Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . .
295
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
297
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
298
Index
299
.
.
.
.
.
.
.
.
.
.
......................................
I Anatomy of the Breast
2
I
Anatomy of the Breast
This description is based upon the work of
Wellings and colleagues,1–3 and Azzopardi,4
who have done much to clarify the anatomic
structure of the breast.
Anatomically the breast can be subdivided into the following structural entities:
Lobe (Fig. I): the human breast contains
15–18 lobes. Each lobe has a main duct
opening in the nipple.
Terminal ductal lobular unit (Figs. II–IV): the
main duct branches and eventually forms
the terminal ductal lobular unit (TDLU),
consisting of the extralobular terminal
duct and the lobule.1
Lobule: the intralobular terminal duct and
ductules, surrounded by a special, loose intralobular connective tissue, form a lobule
(Fig. II). In some nomenclature the ductules
correspond to acini.4
The extralobular and intralobular terminal ducts can be identified by two characteristics:
• the extralobular terminal duct is surrounded by elastic tissue while the intralobular terminal duct and ductules are
not
• the extralobular terminal duct is lined by
columnar cells while the intralobular terminal duct contains cuboidal cells.4
with or without associated cell
changes, such as apocrine metaplasia,
columnar cell hyperplasia and varying
types of epithelial cell changes (Figs.
V–XI)
— larger, palpable cysts involve both the
lobules and a portion of the adjoining
duct system; the lobular epithelium
undergoes apocrine transformation,
resulting in increased fluid secretion.
The accumulated fluid distends the
TDLU and also fills a certain length of
the major pleated duct. If the pleated
duct becomes twisted around its own
axis, the proximal portion of the duct
dilates to form a cyst (Fig. X).
• malignant breast diseases:
— the vast majority of breast cancers
originate from the TDLU and not from
the major ducts. Thus, the conventional
terms “DCIS” or “invasive ductal carcinoma” most frequently refer to a
pathologic lesion originating from the
TDLU.
Fig. I Diagram of the breast illustrating a single
lobe.
Explanation of Terms
• Adenosis (Figs. V and VI): hyperplasia and
hypertrophy of the TDLU.
• Epitheliosis: the epithelial cells proliferate
within preexisting TDLUs.
The anatomic details are important since
certain breast diseases arise from specific
anatomic locations.3,4
Main duct and its branches:
• benign breast diseases:
— benign papilloma(s) arise preferentially in the larger ducts
— ductectasia.
• malignant breast diseases:
— high-grade malignant disease contiguously filling the duct and its branches is
often called “DCIS” (ductal carcinoma
in situ), but it may behave as an invasive, poorly differentiated duct-forming breast cancer (neoductgenesis)
with an unpredictable outcome. These
account for about 15 % of all breast
cancers.5
Terminal ductal lobular unit: according to
Wellings,3 the TDLU is of central importance
because it is the site of origin of:
• benign breast diseases:
— hyperplastic breast changes, such as
fibrocystic change, fibroadenoma, and
various forms of adenosis (sclerosing
adenosis, blunt duct adenosis, etc.),
Fig. II Diagrammatic illustration of the terminal
ductal lobular unit (adapted from Wellings).3
Fig. III Subgross (3 D) histology image of several terminal ductal lobular units (TDLUs).
Anatomy of the Breast
Fig. V Development of adenosis.
Fig. VI Subgross (3 D) histology image of adenosis, proliferation, and hypertrophy of a
TDLU.
Fig. VII Subgross (3 D) histology image of
sclerosing adenosis without calcifications.
Fig. VIII Subgross (3 D) histology image of a
radial scar.
3
Fig. IV Subgross (3 D) histology
image of a subsegmental duct
and normal TDLUs, the origin
of most pathologic entities in
the breast.
a
b
Fig. IXa Schematic presentation of the development of fibrocystic change.
Fig. IXb Schematic presentation of fibrocystic
change with calcifications.
Fig. X Subgross (3 D) histology image of cystic
transformation of TDLUs.
Fig. XI Subgross (3 D) histology image of a
multiloculated cyst surrounded by normal
TDLUs.
II Method for Systematic Viewing
of Mammograms
6
II
Method for Systematic Viewing of Mammograms
A detailed comparison of the left and right
breasts enhances the detection of structural
asymmetries. Perception of subtle alterations can be accentuated by using masking
techniques to enable sequential viewing of
restricted areas of the mammograms.
Masking is equally necessary for viewing
film or digital formats. A hand-held viewer
is an excellent tool for viewing films (Fig.
XII). Digital software can perform this function when viewing soft copy images on digital monitors.
• Horizontal masking: caudal (Fig. XIII) and
cranial (Fig. XIVa, b) aspects
• Oblique masking: cranial (Fig. XV) and
caudal (Fig. XVI) aspects
The goal of perception is to:
• find asymmetric densities (Figs. XIV–XVI)
• detect architectural distortion (Fig. XVII)
• detect changes in the parenchymal contour, such as retraction (Figs. XVIIIa, b and
XIXa), the “tent sign” (Fig. XVIIIc–g) and
protrusion (Fig. XIXb)
• find calcifications on the mammogram.
Fig. XII Perception of small and/or low-contrast lesions on the mammogram is enhanced by the use of a hand-held viewer, which effectively
eliminates extraneous light.
Fig. XIII Horizontal masking, caudal aspect.
Stepwise horizontal masking with the edge of
the viewer when reading film images, and by
the use of specially designed software when
reading digital mammograms, facilitates the
comparison of corresponding regions of the
two breasts. Masking excludes the shaded region from view, focusing attention to the remaining, chosen part of the image.
Method for Systematic Viewing of Mammograms
Fig. XIVa Horizontal masking, cranial aspect.
Right and left mammograms of the mediolateral oblique projections are viewed. Stepwise
horizontal masking facilitates the comparison
of corresponding regions of the two breasts.
7
Fig. XIVb Horizontal masking, cranial aspect, demonstrated on the mediolateral oblique (MLO)
views of Case 72.
8
II
Method for Systematic Viewing of Mammograms
Fig. XVa
Fig. XVb
Fig. XVa Oblique masking, cranial aspect. Alternatively, attention is focused on the corresponding areas of the right and left breasts
using the viewer. Right and left breasts of the
MLO (or lateromedial) projections are viewed
as shown. The masks are initially placed along
the border of the pectoral muscles. Symmet-
rical stepwise movement keeping the masks
parallel to the muscle borders facilitates comparison of the corresponding regions on the
mammograms. This is demonstrated in
Fig. XVb (Case 74). Oblique masking from the
cranial aspect is also very helpful in Cases 76,
78, and 82.
Method for Systematic Viewing of Mammograms
Fig. XVIa
Fig. XVIb
Fig. XVIa Oblique masking, caudal aspect. The
two masks are rotated outwards in a stepwise
fashion, to make comparison of the corresponding areas easier.
Fig. XVIb, c Oblique masking, caudal aspect,
demonstrated on mammograms.
Fig. XVIc
9
10
II Method for Systematic Viewing of Mammograms
Fig. XVIIa Diagrammatic illustration of parenchymal distortion. Asymmetries within the
parenchyma, such as focally increased density
or architectural distortion, may be the only
signs leading to the detection of stellate lesions. Perception of such subtle changes requires careful, systematic comparison of corresponding regions of the parenchyma.
Fig. XVIIb Right and left mammograms, MLO
projections. A radiating structure is outlined in
the right breast.
Fig. XVIIa
Fig. XVIIb
Method for Systematic Viewing of Mammograms
Fig. XVIIc Microfocus magnification view of the architectural distortion facilitates better
analysis of the parenchymal distortion (Case 61).
11
Fig. XVIId Small stellate lesions may be detected by
perceiving disturbances within the normal structure
(arrows) (Case 70). See also Case 77.
12
II Method for Systematic Viewing of Mammograms
Fig. XVIIIa Schematic demonstration of parenchymal contour retraction in the craniocaudal (CC) projection, along the lateral border
of the parenchyma.
Fig. XVIIIb Mammographic illustration of parenchymal contour retraction (arrow) caused by a
small carcinoma.
Fig. XVIIIc Retraction along the posterior border of the parenchyma in the CC projection
gives a special appearance. While the posterior
border is normally smooth and usually concave, retraction may lead to a straightened or
biconvex border resembling the peak of a tent
(“tent sign”).
Fig. XVIIId Mammogram (Case 71) demonstrating a tumor (arrow) causing the “tent sign.” See
also Case 80.
Method for Systematic Viewing of Mammograms
13
Fig. XVIIIe 35-year-old woman, right and left mammograms,
mediolateral oblique projections. No tumor is visible. CC projections on Fig. XVIIIf, g.
Fig. XVIIIf Right breast, CC projection. Typical “tent sign” (retraction along the posterior border) is seen, caused by a carcinoma (arrows).
Fig. XVIIIg Normal left breast, CC projection.
14
II Method for Systematic Viewing of Mammograms
Fig. XIXa Detection of parenchymal contour
retraction may lead to the diagnosis of small
tumors in dense breasts in which the tumor
itself may be hidden. Diagrammatic illustration
of retraction of the parenchymal contour on
the mediolateral oblique projection.
Fig. XIXb Mammographic demonstration of
focal protrusion of the parenchymal contour
(arrow). Compare this contour with the corresponding region of the contralateral breast.
See also Case 80.
III Approach to Viewing
Mammographic Images and
Interpreting the Findings
16
III Approach to Viewing Mammographic Images and Interpreting the Findings
When interpreting a mammographic examination, three steps should be taken:
• determine whether the image is of diagnostic quality in terms of positioning of
the breast, image contrast, and spatial
resolution. Poor-quality images or improper positioning often cause diagnostic
errors
• perform a systematic, step-by-step survey
of the mammograms to evaluate details
of the breast structure while searching for
a lesion. The systematic viewing should
include side-by-side comparison of the
corresponding regions of the right and
left breasts (see Chapter II). Do not stop
searching after you have found the first
lesion
• carefully analyze each detected lesion.
First, place each lesion into one of the five
following classification groups:
I. Circular/oval lesions that may be solitary
or multiple
II. Stellate/spiculated lesions and architectural distortion
III. Calcifications that may or may not be
associated with a tumor. One or more
calcifications may constitute the finding
IV. Thickened skin syndrome: thickened skin
in the dependent portion or most of the
breast, associated with increased density
and a reticular pattern on the mammogram
V. Any combination of two or more of the
above findings.
Second, after classification, each detected
lesion should undergo detailed analysis
(see Chapters IV–VII).
IV Circular/Oval Lesions
Subgross (3D) histology images
Invasive ductal carcinoma with an associated in situ component
A multiloculated tension cyst
Fibroadenomatoid change of a TDLU
Invasive carcinoma with central fibrosis
18
IV Circular/Oval Lesions
Circular/oval lesions may be sharply or
poorly outlined; circular, oval, or lobulated; solitary or multiple.
If a circular/oval lesion is associated with
calcifications, the lesion and the calcifications are analyzed separately. The two analyses are then combined.
Contour and density analysis of circular/
oval lesions should rapidly lead to a benign
or malignant mammographic diagnosis. The
following four steps of analysis can rapidly
lead to mammographic diagnosis:
Analyses
of
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1. Contour
a. sharply outlined
—halo sign
—capsule
b. unsharp contour
2. Density
3. Form, orientation
4. Size
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primary
importance
secondary
importance
Signs of Primary Importance in
Diagnosing Circular/Oval Lesions
Halo Sign or Capsule: Present or
Absent
The halo sign is a narrow radiolucent ring
(Mach band) or a segment of a ring around
the periphery of a lesion characteristic of
benign, growing circular/oval tumors (Cases
17, 21, 49, 50, 52, 53, 56).
A capsule is a thin, curved, radiopaque
line that is seen only when it surrounds
lesions containing radiolucent material (fat
as in a lipoma or fibroadenolipoma, and oil
as in an oil cyst) (Cases 1, 3, 4, 5). Both the
halo sign and the capsule are characteristic
of benign lesions. There are only three rare
exceptions—malignant lesions that may
have a halo sign:
• intracystic carcinoma
• papillary carcinoma
• carcinoma arising within a fibroadenoma
(Case 103).
Comments
• Since the presence of a halo sign is suggestive of a benign lesion, one should
search for it with additional projections,
in particular with microfocus magnification coned-down compression views.
• A capsule surrounding a circular/oval lesion is mammographically demonstrable
when surrounded by radiolucent adipose
tissue and filled with radiolucent adipose
tissue or oil. Since such lesions are always
benign, the diagnostic value of a mammographically demonstrable capsule is
considerable. Evaluation of the density of
a circular/oval lesion should always accompany the search for a halo sign or
capsule.
• The most common circular/oval lesions
are cysts and fibroadenomas. An obvious
halo sign encircling much or all of the
lesion is characteristic of a simple cyst.
• Further differential diagnostic aids: cysts
usually occur in women around menopause, while fibroadenomas arise in
younger women. Cysts are often painful to
pressure while fibroadenomas are not.
• Breast ultrasound is the most valuable
noninvasive adjunctive method for evaluation of the circular/oval lesions.
Density of the Circular/Oval Lesion
The evaluation of density (radiopacity/radiolucency) is of great importance in the
differential diagnosis of circular/oval lesions. Density should be evaluated in relation to the surrounding parenchyma, or, in
the case of fatty involution, to the nipple.
The tumor, in comparison with the surrounding parenchyma, is either:
• radiolucent
• radiolucent and radiopaque combined
• low-density radiopaque (equal to the
surrounding parenchyma), or
• high-density radiopaque (greater than
the surrounding parenchyma).
Once the relative density of the lesion has
been determined, the diagnostic choices are
limited to the following groups:
Radiolucent Circular/Oval Lesions
• Lipoma (Cases 1, 2)
• Oil cyst (Cases 3, 4, 139)
• Galactocele
Radiolucent and Radiopaque Combined
Lesions
• Fibroadenolipoma (breast within a
breast) (Cases 5, 6)
• Galactocele (Cases 7, 8)
• Intramammary lymph node (Cases 9, 10,
47, 123)
• Hematoma (Cases 11, 12, 46)
Low-density Radiopaque Lesions
The surrounding parenchymal structures
(veins, trabeculae, etc.) can be seen
“through” the lesion (superimposed).
• Fibroadenoma (Cases 13, 14, 15, 16, 30,
34, 49, 50, 51)
• Cyst (Cases 17, 18, 19, 52, 53, 56)
• Rarer lesions:
— giant fibroadenoma (Case 21)
— sebaceous cyst (Case 31)
— small cavernous hemangioma (Case
23)
— papilloma, multiple papillomas (Cases
27, 48, 127, 128)
— wart (Cases 24, 25)
— abscess
— phyllodes tumor (Case 26)
— papillary carcinoma
— mucinous carcinoma (Cases 28, 32, 44)
Note: These malignant lesions may lead to
difficulties in diagnosis.
High-density Radiopaque Lesions
These are denser than the surrounding parenchyma. Structures such as veins, trabeculae, etc. usually cannot be seen “through”
the dense lesion.
Signs of Secondary Importance in Diagnosing Circular/Oval Lesions
• Carcinoma (e.g., medullary, invasive ductal NOS [not otherwise specified]) (Cases
29, 33, 41, 54)
• Sarcoma
• Metastases to the breast (Cases 36, 40)
• Phyllodes tumor (Case 37)
• Intracystic papillary tumor
•
•
•
•
Abscess (Cases 38, 42)
Hematoma
Large cavernous hemangioma (Case 151)
Enlarged, pathologic lymph nodes (lymphoma, leukemia, rheumatoid arthritis,
metastases) (Cases 43, 45)
• Large sebaceous cyst (Case 22)
19
Note: All radiolucent, all radiolucent and
radiopaque combined, and most low-density radiopaque lesions are benign.
Signs of Secondary Importance in Diagnosing
Circular/Oval Lesions
These serve to support the mammographic
diagnoses that are made on the basis of
contour and density analysis.
Form and Orientation of the
Circular/Oval Lesions (Fig. XXa, b)
A cyst is generally spherical or ovoid with
smooth borders. Its orientation, when elongated, is usually in the direction of the nipple, following the trabecular structure of
the breast (Cases 53, 56).
A solid tumor (e.g., fibroadenoma, carcinoma) may have a smooth circular/oval or
lobulated border. Its orientation is random,
as it does not tend to be aligned along the
trabecular structure of the breast (Cases 49,
54).
Size
Circular/oval lesions can be grouped into
three categories according to size, providing
for a certain degree of differential diagnosis.
Very Large Circular/Oval Lesions
(> 5 cm)
Few breast tumors grow this large; they
displace much of the breast tissue. The diagnoses can be limited to the following list.
• Radiolucent:
— lipoma (Case 1)
• Radiolucent and radiopaque combined:
— fibroadenolipoma (Cases 5, 6)
• Radiopaque (low-density):
— giant fibroadenoma (Case 21)
— cyst (Cases 17, 56)
— phyllodes tumor (Case 26)
— mucinous carcinoma (Case 32)
• Radiopaque (high-density):
— carcinoma (Case 54)
— sarcoma
— phyllodes tumor (Case 37)
— cyst
— abscess (Cases 38, 42)
— lymph nodes (lymphoma, leukemia,
metastases).
Intermediate-sized Circular/Oval Lesions
(on the order of 2–5 cm)
• Radiolucent:
— lipoma
— oil cyst (Case 139)
• Radiolucent and radiopaque combined:
— fibroadenolipoma
— hematoma (Case 46)
• Radiopaque (low-density):
— fibroadenoma (Cases 13, 49, 50, 55)
— cyst (Cases 39, 52)
— sebaceous cyst
— mucinous carcinoma, which may cause
diagnostic difficulties
• Radiopaque (high-density):
— carcinoma
— sarcoma
— metastases to the breast (Case 40)
— phyllodes tumor
— abscess
— cyst (Case 20)
— sebaceous cyst (Case 22)
— lymph nodes (lymphoma, leukemia,
rheumatoid arthritis, metastases)
(Cases 43, 45)
Smaller Circular/Oval Lesions
(< 2 cm)
• Radiolucent:
— lipoma (Case 2)
— oil cyst (Cases 3, 4)
— galactocele
• Radiolucent and radiopaque combined:
— galactocele (Cases 7, 8)
— intramammary lymph node (Cases 9,
10, 47, 123)
— hematoma (Cases 11, 12)
— fibroadenolipoma (rare when small)
• Radiopaque (low-density):
— fibroadenoma (Cases 14, 15, 16, 30, 34,
51)
— cyst (Cases 18, 19, 53)
Fig. XXa, b The orientation of solid tumors
(fibroadenoma, carcinoma, etc.) is usually
random as they tend not to be aligned along
the trabecular structure of the breast (a), while
the trabecular structure can influence the orientation of a cyst (b).
Less common lesions:
— sebaceous cyst (Case 31)
— intramammary lymph node
— papilloma, multiple papillomas (Cases
127, 128)
— hemangioma (Case 23)
— carcinoma, most frequently mucinous
(Cases 28, 44) or papillary
— wart (Cases 24, 25)
• Radiopaque (high-density):
— carcinoma (Cases 29, 33)
— metastasis to the breast (Case 36)
— lymph nodes (metastases, leukemia,
lymphoma, rheumatoid arthritis)
20
IV Circular/Oval Lesions
Strategy
Workup algorithm
No
After the four steps of analysis (contour,
density, size, form and orientation), one
should have made a tentative mammographic diagnosis of benign or malignant.
The mammographic diagnosis of lipomas,
fibroadenolipomas, oil cysts, intramammary lymph nodes, and most of the fibroadenomas is highly reliable. Many nonpalpable circular/oval lesions will be found in
asymptomatic women. The combined use
of mammography, breast ultrasound and
needle biopsy will lead to definitive diagnosis in most of these cases, so that only a
fraction will require referral to surgical biopsy.
Breast ultrasound is invaluable in the diagnostic workup of circular/oval lesions,
particularly in the differentiation of cystic
from solid lesions.
Microscopic diagnosis can be obtained
using needle biopsy, most often under ultrasound guidance. The workup algorithm of a
circular/oval lesion on the mammogram is
outlined as follows:
Can the diagnosis be made on two views?
Mammographic workup: series of spot
views or magnification views in two projections
Suspicious
for
malignancy
Yes
Fibroadenolipoma
Lymph node
Hyalinized fibroadenoma
Wart
Mammographically
benign
Routine rescreen
Ultrasound
Needle biopsy
Solid
lesion
Satisfactory
microscopic
diagnosis: benign
If either mammography
or needle biopsy
is suspicious for
malignancy
Discussion with the
patient
Open biopsy
Intracystic
tumor
Simple
cyst
Cyst puncture under
ultrasound guidance
Yearly follow-up
Practice in Analyzing Circular/Oval Tumors
Practice in Analyzing
Circular/Oval Tumors
(Cases 1–56)
1
Asymptomatic 85-year-old woman, first
mammographic examination.
Physical Examination
A huge, soft, round lesion is palpable in the
right breast.
Mammography
Fig. 1: Right breast, mediolateral oblique
(MLO) projection. A huge, encapsulated lesion occupies the whole breast. There are
central calcifications.
Analysis
Form: circular/oval
Contour: sharp; a capsule surrounds the
lesion
Density: radiolucent
Size: huge, 12 × 12 cm
Conclusion
The only huge radiolucent breast tumor is a
lipoma.
Comment
The central, ring-like and irregular calcifications, some with a radiolucent center,
appear to be the result of fat necrosis (see
p. 242).
Fig. 1
21
22
IV Circular/Oval Lesions
2
A 34-year-old woman, referred for evaluation of breast pain.
Physical Examination
No palpable tumor.
Mammography
Fig. 2: Right breast, MLO projection. There is
a solitary lesion 5 cm from the nipple in the
upper medial quadrant. There are no associated calcifications.
Analysis
Form: circular/oval
Contour: sharply outlined; the lesion is encapsulated
Density: radiolucent
Size: 20 × 15 mm
Conclusion
The density is the factor determining the
mammographic and final diagnosis of a
lipoma.
Fig. 2
Practice in Analyzing Circular/Oval Tumors
3
A 58-year-old woman previously operated
for a benign lesion in the right breast.
Mammography
Fig. 3 a, b: Right breast, MLO projection. An
oval-shaped, encapsulated radiolucent lesion is seen centrally in the breast (Fig. 3 a,
arrows) without associated calcifications. A
scar is seen between the lesion and the skin
(Fig. 3 b, arrow).
Analysis
Form: circular/oval
Contour: sharp, no halo sign but a definite
capsule
Density: radiolucent
Size: 15 × 12 mm
Conclusion
The history of surgical biopsy at this site
combined with the mammographic appearance is typical for an oil cyst (see p. 242).
Fig. 3a
Fig. 3b
23
24
IV Circular/Oval Lesions
4
A 48-year-old woman with a history of excisional biopsy in the retroareolar region.
Mammography
Fig. 4: Detailed view of the MLO projection
of the left breast. There is a central, partly
calcified radiolucent circular lesion.
Analysis
Form: circular/oval
Contour: sharp
Density: radiolucent
Size: 10 × 10 mm
Comment
There are also eggshell-like calcifications in
the wall of the lesion.
Conclusion
There are three possible circular/oval, radiolucent lesions, all benign (see p. 18). In this
case, the history of biopsy leads to the diagnosis of an oil cyst. With a partially calcified
capsule, it is known as liponecrosis macrocystica calcificans (see p. 242). No further
procedures are necessary.
Note
There are many ring-like calcifications near
the oil cyst. These represent liponecrosis
microcystica calcificans.
Fig. 4
Practice in Analyzing Circular/Oval Tumors
5
Right breast, craniocaudal (CC) projection.
There is a large, centrally located tumor
with no associated calcifications (Fig. 5).
Analysis
Form: circular
Contour: sharp, a capsule is seen
Density: radiolucent and radiopaque combined
Size: 6 × 6 cm
Conclusion
A large, encapsulated lesion with mixed
density is characteristic of a fibroadenolipoma. There is no need for ultrasound or
needle biopsy.
Fig. 5
6
Left breast, MLO projection. A large tumor
fills in the central portion of the breast
(Fig. 6).
Analysis
Form: oval
Contour: sharply outlined, encapsulated; a
halo sign is seen along the anterior border
Density: radiopaque and radiolucent combined (predominantly glandular components)
Size: 7 × 4 cm
Conclusion
This is the typical mammographic appearance of a fibroadenolipoma, which is a mixture of adipose and fibroglandular tissue
surrounded by a capsule. This is also called
a “breast within a breast.” The diagnosis
needs no ultrasound or interventional procedures, since when a circular/oval lesion is
either radiolucent or radiolucent and radiopaque combined on the mammogram, density analysis is decisive in arriving at a benign diagnosis.
Fig. 6
25
26
IV Circular/Oval Lesions
7
This 28-year-old woman noted a lump in
her right breast during nursing.
Mammography
Fig. 7 a: Left breast, CC projection.
Fig. 7 b: Detailed view of the retroareolar
region. A lesion with mixed density is seen
(arrow).
Analysis
Form: circular
Contour: sharply defined
Density: radiolucent and radiopaque combined
Size: 12 × 10 mm
Fig. 7a
Differential Diagnosis
There are four possible diagnostic choices
for a circular/oval lesion of mixed density:
• small hematoma
• galactocele
• fibroadenolipoma
• intramammary lymph node.
Comment
The history points to a galactocele. The
small size helps to differentiate it from a
fibroadenolipoma that is typically large.
The absence of trauma or previous breast
surgery helps to exclude a hematoma or oil
cyst.
Conclusion
The mammographic diagnosis is a benign
lesion, as are all circular/oval lesions with
a combined radiolucent and radiopaque appearance. The history and mammographic
appearance are consistent with a galactocele, which is a milk-filled cyst with a high
fat content, associated with lactation.
Fig. 7b
Practice in Analyzing Circular/Oval Tumors
8
This 42-year-old woman noted a mass in
her breast 2 months following the completion of nursing.
Mammography
Fig. 8 a: Right breast, MLO projection. A tumor is seen 7 cm from the nipple.
Fig. 8 b: Magnification view.
Analysis
Form: oval
Contour: sharply defined
Density: radiolucent and radiopaque combined
Size: 25 × 20 mm
Conclusion
The history and mammographic appearance
are typical of a galactocele. Breast ultrasound will not add any further information.
Needle puncture, although not necessary
for the diagnosis, will yield thick, yellow
fluid.
Fig. 8a
Fig. 8b
27
28
IV Circular/Oval Lesions
9
An 80-year-old asymptomatic woman; her
first mammographic examination.
Physical Examination
A very soft, freely movable superficial lesion
is palpable in the upper outer quadrant of
the left breast; it is clinically benign.
Mammography
Fig. 9 a: Left breast, MLO projection. A solitary lesion is seen in the upper outer quadrant.
Fig. 9 b: A photographic magnification of the
lesion.
Analysis
Form: oval, lobulated
Contour: indistinct; no halo sign is seen
Density: radiolucent and radiopaque combined
Size: 15 × 10 mm
Conclusion
This is one of the four circular/oval lesions
with combined radiolucent and radiopaque
densities (see pp. 18–19), all of which are
benign. Further differentiation can be made
as follows: a fibroadenolipoma is typically
large, a galactocele is associated with nursing, and a hematoma is associated with
trauma. This lesion is an intramammary
lymph node with a typical central radiolucency corresponding to the hilus. No further
procedures are necessary.
Fig. 9a
Fig. 9b
Practice in Analyzing Circular/Oval Tumors
10
First screening examination of this 64-yearold asymptomatic woman.
Physical Examination
No palpable tumor.
Mammography
Fig. 10 a: Right breast, MLO projection. A
small circular lesion is seen in the upper
outer quadrant without associated calcifications.
Fig. 10 b: Magnification view of the lesion.
Analysis
Form: oval
Contour: sharply outlined
Density: radiopaque and radiolucent combined
Size: 6 × 5 mm
Fig. 10a
Conclusion
The mixed density is crucial in classifying
this finding – a small intramammary lymph
node. The central radiolucent area corresponds to the hilus. Intramammary lymph
nodes can be found in any quadrant of the
breast, although they are most often seen in
the upper outer quadrant.
Fig. 10b
29
30
IV Circular/Oval Lesions
11
This 65-year-old woman suffered trauma to
her right breast 8 days earlier.
Mammography
Fig. 11 a: Right breast, CC projection. An
oval-shaped lesion with no associated calcifications is seen 4 cm from the nipple.
Fig. 11 b: Magnified view of the lesion.
Comment
Of the four differential diagnostic choices
for a circular/oval lesion with mixed density, the history of recent trauma leads to
the diagnosis of a hematoma in this case.
Fig. 11a
Fig. 11b
Practice in Analyzing Circular/Oval Tumors
12
This 67-year-old woman experienced
trauma to her right breast 2 weeks earlier.
In addition to a superficial hematoma, she
noted a lump at the site of trauma.
Mammography
Fig. 12 a, b: Right breast, MLO and CC projections. Superficial solitary tumor in the
lower lateral quadrant. No associated calcifications.
Fig. 12 c: Magnified view of the tumor.
Analysis
Form: oval
Contour: sharply outlined
Fig. 12b
Fig. 12a
Fig. 12c
31
Density: radiopaque and radiolucent combined; the radiolucent area is small and is
best seen on the magnified view (arrow)
Size: 20 × 15 mm
Conclusion
Both the history and mammographic appearance indicate a hematoma. This will
eventually develop into an oil cyst.
32
IV Circular/Oval Lesions
13
First screening examination of this asymptomatic 52-year old woman. She was called
back for further assessment of the finding in
the right breast.
Physical Examination
3 cm, firm, freely movable retroareolar tumor. Inverted nipple, no skin changes. Clinically benign.
Mammography
Fig. 13 a, b: Right breast, MLO and CC projections. There is an oval-shaped, lobulated
retroareolar tumor with no associated calcifications. A smaller circular lesion is seen
in the upper outer quadrant 6 cm from the
nipple.
Analysis
Form: oval, lobulated
Contour: sharply outlined
Density: low-density radiopaque
Size: 30 × 15 mm
Comment
When a circular/oval lesion is low-density
radiopaque on the mammogram, contour
analysis is the next step in the mammographic analysis. When present, a halo sign
or a sharp contour indicates that the lesion
is benign. Breast ultrasound may demonstrate a cyst or a solid lesion. If solid, ultrasound-guided needle biopsy will provide
the microscopic diagnosis.
Fig. 13a
Conclusion
This is a mammographically benign tumor.
The smaller lesion, 6 cm from the nipple, is
also a sharply outlined, low-density lobulated tumor, and is also mammographically
benign. Microscopic confirmation is necessary, preferably through ultrasound-guided
core needle biopsy.
Histology
Two fibroadenomas.
Fig. 13b
Practice in Analyzing Circular/Oval Tumors
14
First screening examination of this asymptomatic 42-year old woman. She was called
back for further examination of the solitary,
oval lesion detected on the mammogram of
her right breast.
Physical Examination
2 cm tumor in the upper inner quadrant of
the right breast, clinically benign.
Mammography
Fig. 14 a: Right breast, MLO projection.
There is a tumor with no associated calcifications 6 cm from the nipple in the upper
half of the breast.
Fig. 14 b, c: Magnification views of the tumor and its surroundings in the MLO and CC
projections.
Analysis
Form: oval, lobulated
Contour: mostly sharp, but there are many
disturbing overlying parenchymal shadows,
which make the contour analysis unreliable
Density: low-density radiopaque with
superimposed parenchyma and a blood vessel
Size: 2 × 2 cm
Fig. 14a
Conclusion
Mammography does not provide a reliable
differential diagnosis in this case. Microscopic diagnosis is necessary to differentiate
between an ill-defined fibroadenoma and a
low-density malignant tumor.
Histology
Fibroadenoma.
Fig. 14c
Fig. 14b
33
34
IV Circular/Oval Lesions
15
Asymptomatic 75-year-old woman, first
mammography study.
Physical Examination
Approximately 2 cm freely movable tumor
in the lower outer quadrant of the right
breast. No skin changes.
Mammography
Fig. 15 a, b: Right breast, CC and MLO projections. Circular/oval tumor 7 cm from the
nipple in the lower outer quadrant. No associated calcifications.
Fig. 15 c, d: Microfocus magnification views
of the tumor in the CC and MLO projections.
A partially calcified artery is seen superimposed over the lesion in Fig. 15 d.
Analysis
Form: oval
Contour: mostly unsharp; no definite halo
sign
Density: low-density radiopaque
Size: 20 × 15 mm
Fig. 15a
Conclusion
A tumor with unsharp borders in a 75-yearold woman raises the suspicion of malignancy.
Fine Needle Aspiration Biopsy
Cells suspicious for malignancy.
Histology
Fibroadenoma.
Comment
If part or all of a radiopaque circular/oval
tumor is ill defined, microscopic diagnosis is
mandatory. Core needle biopsy would have
provided a definitive histopathologic diagnosis, avoiding surgical intervention
prompted by the false-positive finding at
cytology.
Fig. 15b
Practice in Analyzing Circular/Oval Tumors
Fig. 15c
Fig. 15d
35
36
IV Circular/Oval Lesions
16
This 33-year-old woman was referred to
mammography for a self-detected tumor
in the right breast.
Mammography
Fig. 16 a, b: Right breast, MLO and CC projections.
Fig. 16 c: Spot magnification view in the CC
projection. A solitary tumor without associated calcifications is seen in the upper
outer quadrant of the breast.
Analysis
Form: oval
Contour: only the posterior border is
sharply outlined; there is a partial halo
sign present on the magnification view (arrows)
Density: low-density radiopaque, equal to
that of the surrounding parenchyma
Size: 15 × 15 mm
Fig. 16a
Conclusion and Comment
The halo sign detected on the spot magnification view in combination with the radiopaque low density suggests the benign nature of this lesion, but the unsharp borders
make tissue diagnosis using core needle biopsy necessary.
Histology
Fibroadenoma.
Fig. 16b
Fig. 16c
Practice in Analyzing Circular/Oval Tumors
17
First screening examination of this 50-yearold woman. She was aware of a lump in her
left breast but did not seek medical advice.
Physical Examination
Tender, 5 cm, clinically benign retroareolar
lesion.
Mammography
Fig. 17 a: Right breast, detailed view of the
CC image. There is a solitary retroareolar
tumor with no associated calcifications.
Analysis
Form: oval
Contour: extensive halo sign
Density: low-density radiopaque
Size: 5 × 5 cm
Fig. 17a
Conclusion
The low-density radiopaque nature of the
lesion in combination with an extensive
halo sign suggests the mammographic diagnosis of a benign lesion, most probably a
cyst.
Comment
The halo sign may be extensive in cysts,
whereas in fibroadenomas the halo sign,
when present, is usually short/partial and
may be difficult to demonstrate. Ultrasound
examination of the circular/oval lesion will
differentiate a solid tumor from a cyst, and
will assist in interventional procedures. The
availability of breast ultrasound provides
the advantage of knowing with a high degree of certainty what the contents of the
oval-shaped lesion are likely to be prior to
puncture. Before the development of breast
ultrasound, pneumocystography after cyst
puncture and air insufflation showed the
inner wall of the cyst cavity in great detail.
The air insufflation may also be used to
prevent cyst recurrence.
Fig: 17 b: Pneumocystogram. Simple cyst,
no intracystic tumor.
Fig. 17b
37
38
IV Circular/Oval Lesions
18
This 80-year-old woman presented with a
large palpable tumor on the chest wall, immediately lateral to the left breast. This
proved to be a lipoma. At mammography
examination, a 3 cm oval-shaped, lobulated
lesion was detected in the right lower medial breast.
Mammography
Fig. 18 a–d: There is a solitary, high-density
sharply outlined oval-shaped tumor in the
lower inner quadrant of the right breast.
Breast Ultrasound
Fig. 18 e, f: Ultrasound images demonstrate
an intracystic papillary lesion.
Specimen Radiographs
Fig. 18 g, h: Specimen radiograph of the excised tumor (Fig. 18 g), which reveals microcalcifications within the intracystic tumor.
A sliced specimen radiograph (Fig. 18 h)
shows the intracystic tumor with calcifications.
Fig. 18a
Fig. 18b
Fig. 18c
Fig. 18d
Histology
Fig. 18 i: Low-power large-section histology: benign intracystic papilloma.
Fig. 18 j–l: Detailed histology images: benign intracystic papilloma.
Comment
The high density of this circular/oval lesion
raised the suspicion of a malignancy. When
sharply outlined, the possibility of an intracystic papillary lesion arises.
Practice in Analyzing Circular/Oval Tumors
Fig. 18e
Fig. 18f
Fig. 18g
Fig. 18h
Fig. 18i–l
39
e
40
IV Circular/Oval Lesions
Fig. 18i
Fig. 18k
Images of histology examination courtesy Riitta Aho, MD, PhD
Fig. 18j
Fig. 18l
Practice in Analyzing Circular/Oval Tumors
41
19
First screening study of this asymptomatic
68-year-old woman.
Physical Examination
No palpable tumor.
Mammography
Fig. 19 a, b: Right breast, MLO and CC projections. A small solitary tumor with no
associated calcifications is seen in the upper
outer quadrant.
Fig. 19 c, d: Microfocus magnification views,
MLO and CC projections.
Analysis
Form: circular
Contour: mostly ill defined
Density: low-density radiopaque; a vein can
be seen superimposed upon the lesion
(Fig. 19 d)
Size: 6 × 5 mm
Conclusion
Although the lesion is of low density, the
lack of a halo sign and the partially unsharp
borders raise the suspicion of malignancy in
this 68-year-old woman.
The benign options include a small papilloma or a cyst. Small lesions surrounded by
a considerable amount of adipose tissue
may be difficult to convincingly demonstrate with breast ultrasound. Stereotactic
guidance will then be necessary for microscopic diagnosis.
Fig. 19a
Fine Needle Aspiration
Cyst fluid with macrophages. No evidence
of malignancy.
Fig. 19b
Fig. 19c, d e
42
IV Circular/Oval Lesions
Fig. 19c
Fig. 19d
Practice in Analyzing Circular/Oval Tumors
43
20
A 54-year-old woman, referred for a lump in
the right breast, first noted 1 week earlier.
Physical Examination
Freely movable, hard lump in the lateral
portion of the right breast, clinically suspicious for malignancy.
Mammography
Fig. 20 a, b: Right breast, MLO and CC projections. Solitary tumor with no associated
calcifications.
Analysis
Form: oval, lobulated
Contour: segments of a halo sign; overlying
parenchyma obscures portions of the border
Density: high-density radiopaque
Size: 5 × 3 cm
Fig. 20a
Fig. 20b
Fig. 20c e
44
IV Circular/Oval Lesions
Conclusion
Although the presence of a halo sign suggests that the tumor is benign, the high
density makes a cancer, phyllodes tumor,
intracystic tumor, or, seldom, a cyst the diagnostic options. Clinical and mammographic examination have a wide range of
differential diagnostic options.
Strategy
Ultrasound is the first ancillary method of
choice to narrow down the differential diagnosis. Ultrasound-guided intervention or
pneumocystography will lead to the final
diagnosis.
Fig. 20 c: Pneumocystogram. Simple cyst, no
intracystic tumor.
Fig. 20c
Practice in Analyzing Circular/Oval Tumors
21
This 21-year-old woman detected a large
tumor in her left breast.
Physical Examination
Huge, approximately 10 cm, firm but movable tumor filling most of the left breast.
Mammography
Fig. 21: Left breast, MLO projection.
Analysis
Form: oval
Contour: sharply outlined; extensive halo
sign
Density: low-density radiopaque, equal to
parenchyma
Size: 11 × 8 cm
Conclusion
The presence of a very extensive halo sign in
combination with the low-density radiopaque appearance, despite the large size, suggests a mammographically benign tumor. In
a patient this young, the description is characteristic of a giant fibroadenoma.
Histology
Giant fibroadenoma.
Fig. 21
45
46
IV Circular/Oval Lesions
22
A 67-year-old woman first noted a tumor in
her right breast many years ago but had not
sought medical help. This is the first screening examination.
Mammography
Fig. 22 a, b: Right breast, MLO and CC projections. A solitary tumor is located in the
upper outer quadrant, immediately under
the skin. There are no associated calcifications.
Analysis
Form: circular
Contour: sharply outlined; the presence of
an air pocket surrounding the lesion suggests that it is protruding from the skin surface
Size: 3 × 3 cm
Location: intracutaneous and subcutaneous; the overlying skin is not thickened
Conclusion
Clinical examination reveals a sebaceous
cyst. The large lesion size and the risk for
inflammation prompted surgical removal.
Histology
Sebaceous cyst.
Fig. 22a
Fig. 22b
Practice in Analyzing Circular/Oval Tumors
47
23
An asymptomatic 63-year-old woman, first
screening study.
Physical Examination
No palpable tumor.
Mammography
Fig. 23 a: Left breast, MLO projection. A solitary tumor is located in the lower half of the
breast. Fig. 23 b, c: Microfocus magnification views in the MLO and CC projections.
Numerous microcalcifications are seen in
the tumor.
Analysis of the Tumor
Form: round, lobulated
Contour: sharply outlined
Density: low-density radiopaque
Size: 12 × 15 mm
Analysis of the Calcifications
Distribution: within the tumor
Form: round and elongate, smooth bordered
Density: high, uniform
Size: small, variable
Fig. 23a
Fig. 23b
Conclusion
Although the tumor mass has mammographically benign characteristics, the varying size and shape of the calcifications make
biopsy necessary.
Histology
Cavernous hemangioma.
Fig. 23 d: Low-power photomicrograph of
the lesion showing the typical structure of
a cavernous hemangioma. (H&E [hematoxylin and eosin], 12.5 ×).
Fig. 23 e: High-power view of the lesion's
periphery, demonstrating its cavernous
structure. (H&E, 200 ×).
Fig. 23c
Fig. 23d, e e
48
IV Circular/Oval Lesions
Fig. 23d
Fig. 23e
Practice in Analyzing Circular/Oval Tumors
24 and
25
Figs. 24 and 25: Two cases of warts. Most
warts have a typical mammographic appearance. The borders are sharply outlined
with a multilobulated contour. The air outlining the fine, papillary surface emphasizes
its structure.
Comment
Well-trained technologists are familiar with
the appearance of typical skin lesions and
should always inform the radiologist of
their presence and location.
Fig. 24
Fig. 25
49
50
IV Circular/Oval Lesions
26
First mammography examination of this
asymptomatic 37-year-old woman.
Physical Examination
A freely movable tumor, 7 × 6 cm, fills the
upper outer quadrant of the left breast.
There is no skin retraction.
Mammography
Fig. 26 a, b: Left breast, MLO and CC projections. A large tumor associated with coarse
calcifications is seen in the upper outer
quadrant.
Analysis of the Tumor
Form: oval
Contour: sharply outlined; extensive halo
sign in Fig. 26 a
Density: equal to that of the parenchyma
Size: 7 × 6 cm
Fig. 26a
Analysis of the Calcifications
Coarse, high-density, mammographically
benign type.
Comment
Huge, sharply outlined radiopaque tumors
are typically phyllodes tumors or, rarely,
cysts. In this case the calcifications indicate
the diagnosis of a phyllodes tumor.
Histology
Benign phyllodes tumor (cystosarcoma
phyllodes).
Fig. 26 c: Typical leaf-like (phyllodes) projection of a duct-like structure into the lumen.
There are large variations in the cellularity
of the stromal component. (H&E, 100 ×)
Fig. 26b
Fig. 26c
Practice in Analyzing Circular/Oval Tumors
51
27
A 73-year-old woman first felt a tender
mass behind the left areola 1 week earlier.
Blood was expressed from the nipple during
the mammographic examination.
Mammography
Fig. 27 a, b: Right breast, MLO and CC
projections. There are several retroareolar
tumors, the largest containing a single,
benign-type calcification.
Analysis
Location: retroareolar
Form: round and oval
Contour: sharply defined, except for the one
with the calcification
Density: low-density radiopaque; a vein is
well seen superimposed over the tumors
(Fig. 27 b)
Size: 0.5–2.0 cm
Conclusion
The tumors with sharp borders and low
density are mammographically benign, but
the mammographic diagnosis of the largest
tumor is uncertain due to its partially unsharp border. Galactography may assist in
the diagnosis.
Fig. 27a
Galactography
(CC projection, Fig. 27 c)
A dilated duct contains several intraductal
filling defects. The benign/malignant nature
of these intraductal tumors cannot be determined radiologically1
Histology
Multiple benign intraductal papillomas
(H&E) (Fig. 27 d).
Fig. 27b
Fig. 27c, d e
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Fig. 27c
Fig. 27d
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53
28
First mammography examination of this
asymptomatic 80-year-old woman.
Mammography
Fig. 28 a: Right breast, MLO projection. The
mammogram was interpreted as normal.
Seven months later the patient felt a lump
in the lower half of the right breast.
Repeat Mammography
Fig. 28 b: Right breast, MLO projection; 4 cm
from the nipple (arrows) there is an ill-defined tumor.
Fig. 28 c: Microfocus magnification view in
the MLO projection. The tumor (arrows) has
no associated calcifications.
Analysis
Form: ovoid, highly lobulated
Contour: partially unsharp, no halo sign
Density: low-density radiopaque
Size: approximately 1 × 1 cm
Fig. 28a
Comment
Although this circular/oval tumor has a low
density, the contours are unsharp, which
raises the suspicion of malignancy. This suspicion is strengthened by the fact that the
tumor has developed within a short time in
an 80-year-old woman. Mucinous and papillary carcinomas may have a low density at
mammography.
Conclusion
Any circular/oval radiopaque tumor with
unsharp borders and no demonstrable halo
sign should lead to the suspicion of malignancy, regardless of the density.
Fig. 28b
Fig. 28c e
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Histology
Mucinous carcinoma. No lymph node metastases.
Follow-up
The woman died 5 years 10 months later
from cerebral infarction at the age of 86
years. There was no evidence of breast cancer at the time of death.
Fig. 28c
29
This 74-year-old woman observed a slowly
growing lump in the right breast during the
past year.
Physical Examination
The palpable tumor in the right breast is
clinically malignant.
Mammography
Fig. 29: Right breast, CC view. A circular/oval
tumor is seen 5 cm from the nipple in the
central portion of the breast. There are no
associated calcifications.
Analysis
Form: round, partially lobulated
Contour: ill defined with a few spicules
Density: high-density radiopaque
Size: 2 × 2 cm
Conclusion
Mammographically malignant tumor.
Histology
Well-differentiated ductal carcinoma. No
lymph node metastases.
Fig. 29
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55
30
First screening study of this 40-year-old
asymptomatic woman.
Physical Examination
No palpable tumor.
Mammography
Fig. 30 a: Right breast, CC projection. An
oval-shaped lesion is located in the medial
half of the breast. No associated calcifications. Fig. 30 b, c: Microfocus magnification
mammography in the CC and LM (lateromedial) projections. Fig. 30 d: Specimen radiograph.
Fig. 30a
Analysis
Form: oval
Contour: no definite halo sign, sharply outlined, but overlying parenchyma partially
obscures the borders of the tumor
Density: low-density radiopaque
Size: 1 × 1 cm
Conclusion
Mammography suggests a benign tumor,
but microscopic confirmation is necessary.
This can be obtained using ultrasoundguided core needle biopsy.
Histology
Fibroadenoma.
Fig. 30b
Fig. 30c, d e
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Fig. 30c
Fig. 30d
Practice in Analyzing Circular/Oval Tumors
31
Fig. 31 a, b: Right breast, MLO and CC projections. There is a solitary tumor in the
upper outer quadrant. There are no associated calcifications.
Analysis
Location: intradermal and subdermal
Form: oval
Contour: sharp
Density: low-density radiopaque; a vein and
parenchymal structures can be seen superimposed over the tumor. The presence of an
air pocket (best seen on the MLO projection)
suggests that the lesion protrudes from the
skin surface
Size: 2 × 3 cm
Conclusion
This is a mammographically benign tumor.
Clinical examination reveals a typical sebaceous cyst. No further diagnostic procedures are necessary.
Fig. 31a
Fig. 31b
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32
This 65-year-old woman discovered a hard
lump in the right breast 1 week earlier.
Physical Examination
6 × 6 cm freely movable tumor, hard at palpation. No skin changes.
Mammography
Fig. 32 a, b: Right breast, detailed views of
the MLO and CC projections show a large,
solitary tumor with no associated calcifications.
Analysis
Form: circular, lobulated
Contour: irregular, no halo sign
Density: low-density radiopaque; structural
elements can be seen through the tumor
Size: 5 × 5 cm
Conclusion
Although this tumor is of low density, it is
not sharply outlined and there is no halo
sign, suggesting a malignant tumor in this
65-year-old woman. A ductal carcinoma of
this size would have a much higher density.
The combination of older age, low-density
radiopaque appearance despite the large
size, the irregularly lobulated shape, and
the partially ill-defined contour suggest
mucinous carcinoma.
Fig. 32a
Histology
Mucinous carcinoma without axillary
lymph node metastases.
Fig. 32 c: High-power magnification of the
mucinous carcinoma near the tumor border.
(H&E, 200 ×).
Fig. 32 d: Clusters of well-differentiated cancer cells floating in a mucinous background
(H&E, 400 ×).
Follow-up
The woman was still alive 20 years later
with no evidence of breast cancer.
Fig. 32b
Practice in Analyzing Circular/Oval Tumors
Fig. 32c
Fig. 32d
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33
The first screening study of this asymptomatic 65-year-old woman revealed a small,
solitary tumor in the lateral portion of the
left breast.
Physical Examination
No palpable tumor.
Mammography
Fig. 33 a, b: Left breast, MLO and CC projections. A solitary tumor is seen in the upper
outer quadrant, without associated calcifications.
Fig. 33 c, d: Microfocus magnification views
in the MLO and CC projections.
Fig. 33 e: Lateromedial view with biopsy localization plate.
Fig. 33 f: The hook localizes the tumor for
biopsy.
Analysis
Form: oval
Contour: partly unsharp; an obvious comet
tail is seen extending from the tumor in an
anterior and caudal direction in Fig. 33 a
Density: high-density radiopaque
Fig. 33a
Conclusion
This small, oval-shaped tumor has high
density and a reproducible comet-tail sign.
These signs are characteristic of a mammographically malignant tumor.
Histology
Well-differentiated
ductal
carcinoma,
7 × 6 mm. No axillary lymph node metastases.
Follow-up
The woman died 16 years later from cardiovascular disease. There was no evidence of
breast cancer at the time of death.
Fig. 33b
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61
Fig. 33c
Fig. 33d
Fig. 33e, f e
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Fig. 33e
Fig. 33f
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34
This 38-year-old woman with a history of
multiple breast abscesses noted a small,
hard lump in the lower medial quadrant of
the left breast.
Physical Examination
A solitary, superficial lump in the subcutaneous tissue measuring about 1 cm in diameter.
Mammography
Fig. 34 a, b: Left breast, MLO and CC projections, 3 cm from the nipple in the lower
outer quadrant there is a solitary, high-density, circular lesion 7 mm in diameter. There
are no associated calcifications.
Fig. 34 c: Microfocus magnification in the CC
projection. The high-density lesion has illdefined borders; it is mammographically
malignant.
Fig. 34 d: Ultrasonography confirms the
mammographic findings.
Conclusion
Mammographically malignant tumor.
Fig. 34a
Cytology
Malignant cells.
Histology
10 × 7 mm moderately differentiated ductal
carcinoma. Histology also demonstrated
mammographically occult lobular carcinoma in situ over a 40 × 30 mm region surrounding the lesion.
Fig. 34b
Fig. 34c
Fig. 34d
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First screening study of this 57-year-old
asymptomatic woman.
Mammography
Fig. 35 a: Left breast, detail of the MLO projection. No mammographic abnormality is
seen.
Fig. 35 b–d: Second screening examination
at the age of 60 years. Left breast, details
of the MLO and CC projections; 4 cm from
the nipple there is a 6 mm, de novo, lobulated tumor in the upper half of the breast.
Analysis
Form: circular/oval, lobulated
Contour: unsharp, no halo sign
Density: low-density radiopaque
Size: 6 × 4 mm
Comment
De novo appearance of an unsharp, lobulated, circular/oval tumor in a 60-year-old
woman leads to the suspicion of malignancy. The benign differential diagnostic
option is a papilloma.
Fig. 35a
Histology
Tumor-forming in situ carcinoma, diameter
6 mm.
Follow-up
The woman died 7 years and 8 months later
from myocardial infarction. There was no
evidence of breast cancer at the time of
death.
Fig. 35b
Practice in Analyzing Circular/Oval Tumors
Fig. 35c
Fig. 35d
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36
First screening study of this 66-year-old
asymptomatic woman.
Mammography
Fig. 36 a: Right breast, MLO projection. Normal mammogram.
Two years later the patient presented with a
2-month history of a mass in the axillary
portion of the right breast and a mass in the
right iliac fossa.
Repeat Mammography
Fig. 36 b: Right breast, MLO projection. A
tumor is seen high up in the axillary portion
of the breast. No associated calcifications
were demonstrable.
Analysis
Form: oval, lobulated
Contour: partly sharply outlined, but there
are also short spicules extending from the
tumor periphery
Density: high-density radiopaque
Size: 3 × 2.5 cm
Fig. 36a
Conclusion
This tumor has developed within 2 years, is
highly dense, and has unsharp borders with
short spicules. It is a mammographically
malignant tumor.
Histology
Lymphoma (in both the breast and the iliac
fossa).
Follow-up
The woman was still alive 18 years later at
the age of 84 years.
Fig. 36b
Practice in Analyzing Circular/Oval Tumors
37
A 49-year-old woman with a 6 × 4 cm hard,
centrally located, freely movable tumor in
the left breast.
Physical Examination
Benign tumor.
Mammography
Fig. 37 a: Left breast, CC projection. There is
a large, centrally located tumor with no
associated calcifications.
Fig. 37a
Analysis
Form: oval, lobulated
Contour: sharply outlined (part of the contour is obscured by the retroareolar fibrosis), no halo sign is demonstrable
Density: high
Size: 6 × 5 cm
Comment
A huge, sharply outlined, radiopaque tumor
in a woman of menopausal age raises the
suspicion of a cyst or a phyllodes tumor.
Ultrasound can easily differentiate between
the two. Solid tumors should be subjected
to microscopic diagnosis.
Histology
Benign phyllodes tumor.
Fig. 37 b: Low-power view showing the leaflike structure typical of cystosarcoma phyllodes (H&E, 100 ×).
Fig. 37 c: Detail of Fig. 37 b (H&E, 100 ×).
Fig. 37b
Fig. 37c
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38
A 40-year-old woman first noted a rapidly
growing retroareolar tumor in the left
breast 4 weeks earlier, associated with fever,
pain, tenderness, and periareolar erythema.
Physical Examination
Inspection: 7 × 6 cm area of periareolar erythema and extensive peau d’orange.
Palpation: Left breast heavier than right.
Warm, tender, large retroareolar tumor. Enlarged axillary lymph nodes. The patient is
febrile.
Mammography
Fig. 38 a, b: MLO and CC projection. There is
a large, 7 × 6 cm, dense retroareolar tumor
with unsharp borders. It is associated with
nipple retraction and skin thickening over
the areola and lower portions of the breast.
Comment
An inflammatory carcinoma and a huge retroareolar abscess could both produce this
clinical picture. However, an inflammatory
cancer would result in an extensive reticular pattern on the mammogram caused by
axillary lymphatic obstruction. Ultrasound
is not the primary diagnostic procedure of
choice since necrosis, if present within a
large carcinoma, can mimic the ultrasound
image of an abscess cavity. Ultrasoundguided needle puncture can establish the
correct diagnosis.
Fig. 38a
Puncture
60 mL of pus was aspirated.
Fig. 38 c: Mammography of the left breast
after puncture and air insufflation: a small
amount of air is seen in the much contracted
abscess cavity (arrow).
Follow-up
The patient was placed on oral antibiotics,
and 9 days later the abscess was incised and
drained. Alternatively, abscesses can be successfully drained and irrigated through a
pig-tail catheter when they are in a more
acute stage, so that surgery can often be
avoided.
Repeat mammography in the MLO projection (Fig. 38 d) 5 weeks later shows only a
slight degree of fibrosis and no underlying
tumor.
Fig. 38b
Practice in Analyzing Circular/Oval Tumors
Fig. 38c
Fig. 38d
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39
This 36-year-old woman discovered a lump
in her right breast 2 weeks earlier.
Physical Examination
2 cm freely movable tumor in the upper
inner quadrant of the right breast. No skin
changes.
Mammography
Fig. 39 a, b: Right breast, MLO and CC projections. There is an oval-shaped tumor in
the upper inner quadrant with no associated calcifications.
Analysis
Form: oval shaped
Contour: mostly ill-defined; there is a short
segment of a halo sign (arrows)
Density: low-density radiopaque
Size: 3 × 2.5 cm
Conclusion
The mostly ill-defined tumor margin leads
to the suspicion of malignancy in spite of
the short halo sign. Needle biopsy is recommended.
Fig. 39a
Puncture
5 mL of straw-colored fluid was aspirated.
Cytology
Inflammatory cells. No malignant cells. Abscess? Inflamed cyst?
Fig. 39 c, d: Pneumocystography. The inferior and anterior wall of the cyst is sharp,
but the upper and posterior wall is irregular
and thickened, best seen on the CC projection (Fig. 39 d). Tumor in the cyst wall?
Histology
Medullary cancer in a 2-cm segment of the
wall of a cyst.
Fig. 39 e: Cystic degeneration of a medullary
cancer with a thin rim of viable tumor tissue. (H&E, 20 ×).
Fig. 39 f: Typical histologic picture of a medullary carcinoma with poorly differentiated cancer cells and intense lymphoplasmocytic infiltration. (H&E, 400 ×).
Fig. 39 g: The very high proliferation rate of
the tumor cells is demonstrated by immunohistochemical staining for Ki-67 antigen.
There is a tripolar mitosis (arrow). (400 ×).
Fig. 39b
Practice in Analyzing Circular/Oval Tumors
71
Comment
Needle puncture without imaging guidance
can be misleading.
Follow-up
The patient died 16 years 5 months later of
metastatic breast carcinoma at the age of 52
years.
Fig. 39c
Fig. 39d–g e
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Fig. 39d
Fig. 39e
Practice in Analyzing Circular/Oval Tumors
Fig. 39f
Fig. 39g
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40
A 49-year-old woman with an 18-month
history of malignant melanoma sought
medical attention for a mass in the right
breast and in both axillas.
Physical Examination
There is a hard, freely movable lump in the
lateral half of the right breast, 10 cm from
the nipple, and large, bilateral axillary
lymph nodes.
Mammography
Fig. 40: Right breast, MLO projection shows
two oval-shaped tumors near the chest
wall.
Analysis of the Larger Tumor
Form: oval, lobulated
Contour: unsharp
Density: high-density radiopaque
Size: 4 cm
Conclusion
This is a mammographically malignant tumor.
Histology
Multiple malignant melanoma metastases.
Fig. 40
Practice in Analyzing Circular/Oval Tumors
41
A 66-year-old woman was referred for a
self-detected lump in the upper outer quadrant of the right breast, clinically suspicious
for malignancy.
Mammography
Fig. 41 a: Right breast, MLO projection.
There is a solitary tumor 4 cm from the
nipple, in the upper half of the breast. There
are no associated calcifications.
Fig. 41 b: Photographic enlargement of the
spot compression view of the tumor.
Analysis
Form: circular
Contour: mostly ill defined
Density: high-density radiopaque
Conclusion
The combination of the high-density radiopaque appearance and the poorly defined
contour leads to a mammographically malignant diagnosis.
Fig. 41a
Histology
Partly ductal, partly papillary carcinoma
without lymph node metastases.
Fig. 41b
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42
A 45-year-old woman detected a lump in
her left breast 1 month earlier.
Physical Examination
There is a 10 cm tumor located centrally in
the left breast and peau d’orange over the
lower half of the breast but no signs of inflammation.
Mammography
Fig. 42 a, b: Left breast, MLO and CC projections. A large, oval tumor fills in the central
portion of the breast. There are no associated calcifications. The pectoral muscle appears to be infiltrated. There is a pathologically enlarged lymph node in the axilla, but
there is no extensive reticular pattern on
the mammogram.
Analysis
Form: oval
Contour: unsharp, no halo sign
Density: high-density radiopaque
Size: 10 × 10 cm
Fig. 42a
Comment
High-density, ill-defined circular/oval lesions localized behind the areola should
raise the suspicion of an abscess, despite
the presence of signs of malignancy. However, a malignant tumor of this size with
associated enlarged axillary lymph nodes
and peau d’orange would be expected to
cause lymphedema (skin thickening and a
reticular pattern) over much of the breast.
The ancillary method of choice is ultrasound-guided needle aspiration. Failure to
drain pus with a large-bore needle should
heighten the suspicion of malignancy.
Fig. 42b
Practice in Analyzing Circular/Oval Tumors
Fig. 42 c, d: Left breast, MLO and CC projections after puncture, removal of 80 mL pus,
and insufflation of air.
Conclusion
Abscess with a thick irregular wall.
Histology
Abscess, no evidence of malignancy.
Fig. 42c
Fig. 42d
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43
This is the first screening study of this
55-year-old asymptomatic woman. She
was called back for further examination of
the finding in the axillary regions of the
mammograms.
Physical Examination
No abnormalities in the breasts. Enlarged
axillary lymph nodes bilaterally.
Mammography
Fig. 43 a: Left breast, MLO projection. Normal breast. Enlarged, dense axillary lymph
nodes.
Comment
When the axillary lymph nodes are enlarged and breast disease can be ruled out
with certainty by physical examination,
mammography, and ultrasonography, the
following diagnoses should be considered:
rheumatoid arthritis, psoriasis, eczema,
lymphoma, and leukemia.
Magnification Immersion Radiography of
the Left Hand
Radiographic changes in the soft tissues and
bone, typical of rheumatoid arthritis
(Fig. 43 b).
Fig. 43a
Practice in Analyzing Circular/Oval Tumors
Fig. 43b
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44
This 82-year-old woman noticed a lump in
her left breast.
Physical Examination
Freely movable tumor below the nipple,
clinically benign.
Mammography
Fig. 44 a: Left breast, MLO projection, detailed view of the lower half of the breast.
Fig. 44 b: Left breast, CC projection, detailed
view.
Fig. 44 c, d: Left breast, microfocus magnification views in the MLO and CC projections.
There is a solitary tumor with no associated
calcifications, 5 cm from the sharply outlined nipple.
Fig. 44a
Analysis
Form: ovoid, lobulated
Contour: unsharp, no halo sign; compare
with the nipple, which is sharply outlined
Density: low-density radiopaque, equal to
the density of the nipple
Size: 1 × 1 cm
Conclusion
The unsharp borders and absence of a halo
sign make this solitary tumor, newly occurring in an 82-year-old woman, suggestive of
malignancy.
Histology
Mucinous carcinoma. No axillary lymph
node metastases.
Comments
Evaluation of the density of a circular/oval
tumor in a breast that has undergone involution can be made by comparison with the
density of the nipple.
The low-density radiopaque appearance on
the mammogram can be explained by the
high mucinous content, since mucin absorbs less radiation than the fibrous stroma
in invasive ductal carcinoma. Mucinous carcinoma is also difficult to detect with ultrasound.
Fig. 44b
Practice in Analyzing Circular/Oval Tumors
Fig. 44c
Fig. 44d
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45
Fig. 45 a, b: Mammographic picture of pathologically enlarged axillary lymph nodes
in a 68-year-old woman with chronic lymphatic leukemia.
Fig. 45a
Fig. 45b
Practice in Analyzing Circular/Oval Tumors
46
Second screening examination in a 63-yearold asymptomatic woman, who was called
back for evaluation of the mammographic
finding.
Physical Examination
No palpable tumor.
Mammography
Fig. 46 a: Right breast, medial portion of the
CC projection. A solitary tumor is seen 6 cm
from the nipple. There are no associated
calcifications.
Fig. 46a
Analysis
Form: oval, lobulated
Contour: the medial border is sharply outlined with a halo sign
Density: low-density radiopaque
Size: 2 × 1.5 cm
Conclusion
Mammographically benign tumor, which
has developed since the first screening examination.
Fine Needle Biopsy
Fig. 46 b: Mammogram following fine needle aspiration biopsy shows the typical appearance of a hematoma, which hides the
tumor completely.
Cytology
Benign epithelial cells.
Fig. 46 c: Two weeks later, preoperative localization. The resolving hematoma still obscures the tumor.
Fig. 46b
Histology
Benign intraductal papilloma.
Comment
As this case demonstrates, a hematoma
caused by needle puncture can completely
obscure a lesion, making the mammographic diagnosis impossible. For this reason, needle puncture should never precede
mammography.2
Fig. 46c
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First screening study of this asymptomatic
47-year-old woman.
Physical Examination
No palpable tumor.
Mammography
Fig. 47 a: Right breast, MLO projection. A
solitary lesion is seen in the upper half of
the breast, 6 cm from the nipple.
Fig. 47 b: Microfocus magnification view.
Analysis
Form: oval, lobulated
Contour: partly unsharp, no halo sign
Density: radiolucent and radiopaque combined (central radiolucency)
Size: approximately 1 cm
Conclusion
The mixed density is the crucial factor determining the benign nature of this tumor.
Further differential diagnosis follows that
described in the Conclusion of Case 9.
The radiolucent part corresponds to the hilus of this intramammary lymph node. No
further procedures are indicated.
Fig. 47a
Fig. 47b
Practice in Analyzing Circular/Oval Tumors
48
A 29-year-old woman first detected a lump
in the upper lateral quadrant of the left
breast 2 months earlier.
Physical Examination
An elongated, firm, movable, nodular tumor
extending from the nipple to the upper
outer quadrant, clinically benign.
Mammography
Fig. 48 a, b: Left breast, CC projection, contact and magnification views of the lateral
half of the breast. A 10-cm long, multinodular tumor resembling a set of rosary beads
extends laterally from the nipple. There are
associated calcifications.
Analysis of the Lesion
Location: fills in an entire lobe
Form: elongate, multinodular
Contour: smooth, undulating
Density: low-density radiopaque
Fig. 48a
Conclusion
The mammographic appearance is that of
the dilated duct system of a single lobe.
Analysis of the Calcifications
Location: within the dilated ducts
Form: irregular
Density: the largest calcification appears
hollow, and the smaller calcifications are
very dense
Contour: smooth, regular
Comment
Mammographically benign-type calcifications, most likely within papillomas (see
p. 242).
Conclusion
The multiple intraductal calcifications, typical of multiple papillomas, within an irregularly dilated duct system of a lobe in a
young woman, suggest the diagnosis of juvenile papillomatosis (“Swiss cheese” disease).3
Histology
Juvenile papillomatosis. No evidence of malignancy.
Fig. 48b
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Fig. 49 a, b: Right breast, detailed views
from the MLO and CC projections. Solitary
tumor, no associated calcifications.
Analysis
Form: oval
Contour: halo sign over much of the border
Density: low-density radiopaque, details of
parenchymal structure can be seen superimposed over the tumor
Conclusion
Mammographically benign tumor.
Cytology
Benign epithelial cells.
Histology
Fibroadenoma.
Fig. 49a
Fig. 49b
Practice in Analyzing Circular/Oval Tumors
50
Fig. 50: Right breast, detail from the MLO
projection. Solitary tumor, no associated
calcifications.
Analysis
Form: oval
Contour: sharply outlined, definite halo sign
along the posterior border
Density: low-density radiopaque; vein and
parenchymal elements can be seen superimposed over the tumor
Size: 4 × 3 cm
Conclusion
All mammographic signs indicate a benign
tumor.
Histology
Fibroadenoma.
Fig. 50
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Fig. 51 a: Right breast, CC projection. A solitary tumor is seen in the central portion of
the breast with no associated calcifications.
Fig. 51 b: Spot compression microfocus
magnification view of the tumor, CC projection.
Analysis
Form: oval
Contour: unsharp, poorly defined
Density: low-density radiopaque; equal to
that of the parenchyma
Size: 15 × 12 mm
Fig. 51a
Conclusion
The poorly defined borders of the tumor
raise the suspicion of malignancy, making
microscopic examination mandatory.
Histology
Fibroadenoma. No evidence of malignancy.
Fig. 51b
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89
52
This 68-year-old woman presented with a
palpable tumor in the upper outer quadrant
of her left breast.
Mammography and Ultrasound
Fig. 52 a, b: Details of the MLO (Fig. 52 a)
and CC (Fig. 52 b) projections. There is a
circular/oval non-calcified lesion with a
“comet tail sign” corresponding to the palpable tumor.
Fig. 52 c, d: Spot-microfocus magnification
images in the MLO (Fig. 52 c) and CC
(Fig. 52 d) projections. The circular, lowdensity lesion is mostly sharply outlined,
and the microfocus magnification confirms
the presence of a “comet tail.” Both components require further examination with
hand-held ultrasound.
Fig. 52a
Fig. 52b
Fig. 52c
Fig. 52d
Fig. 52e–m e
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Fig. 52 e, f: The hand-held ultrasound images demonstrate both an intracystic tumor
(the cystic component shows through
transmission) and, corresponding to the
comet-tail sign, there is acoustic shadowing.
Fig. 52e
Fig. 52f
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91
Histology
Fig. 52 g, h: Large format thin-section low(Fig. 52 g)
and
intermediate-power
(Fig. 52 h) magnification histology images.
The intracystic growth is an 11 mm grade 1
in situ papillary carcinoma. Immediately adjacent to it there is a 19 × 11 mm estrogen/
progesterone receptor (ER/PR)-positive
moderately differentiated invasive ductal
carcinoma. The thin, smooth fibrous capsule
of the cystic cavity outlined by adipose tissue accounts for the sharply outlined part of
the circular lesion on the mammogram,
while the adjacent invasive ductal carcinoma corresponds to the “comet-tail” sign
on the mammogram and to the acoustic
shadowing on the ultrasound images.
Fig. 52g
Fig. 52h
Fig. 52i–m e
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Fig. 52 i: Large-format thin-section lowpower magnification showing both the intracystic papillary cancer and the adjacent
invasive ductal carcinoma.
Fig. 52 j, k: Large-format thin-section intermediate-power magnification histology images demonstrating the invasive ductal carcinoma (Fig. 52 j) within the rectangle on
Fig. 52 i, and the intracystic papillary carcinoma (Fig. 52 k) within the dashed rectangle on Fig 52 i.
Fig. 52 l, m: Alpha-smooth-muscle actin
stain demonstrating the lack of myoepithelial cells within the papillary structures.
Comment
The diagnostic workup of intracystic breast
lesions should include both mammography
and ultrasound examination. Imaging can
demonstrate the presence of an intracystic
growth, but histologic examination of the
completely excised tumor is necessary for
final diagnosis, because the benign and malignant intracystic tumors may have similar
appearance at imaging. Cases such as this
one with an adjoining comet-tail sign are
more likely to be malignant.
Fig. 52i
Fig. 52j
Fig. 52k
Practice in Analyzing Circular/Oval Tumors
Fig. 52l
Fig. 52m
93
94
IV Circular/Oval Lesions
53
This 63-year-old man felt a tumor behind
his left areola.
Mammography and Ultrasound
Fig. 53 a, b: Left breast, MLO and CC projections. A solitary, oval-shaped, high-density
tumor is seen behind the nipple–areola
complex. No associated calcifications are
demonstrable.
Fig. 53 c: Ultrasound image of the solitary,
oval tumor.
Fine Needle Aspiration Biopsy
Fig. 53 d–g: Ultrasound-guided fine needle
aspiration biopsy: the presence of mucoid
tissue fragments and monomorphic stromal
cells give the impression that the lesion is a
mesenchymal tumor.
Fig. 53a
Fig. 53b
Practice in Analyzing Circular/Oval Tumors
95
Fig. 53c
Fig. 53d
Fig. 53e
Fig. 53f
Fig. 53g
Fig. 53h–l
e
96
IV Circular/Oval Lesions
Histology
Fig. 53 h, i: Preoperative hand-held ultrasound (Fig. 53 h) and postoperative, lowpower large-section histology images of
the tumor (Fig. 53 i). The excised tumor
was soft and somewhat gelatinous.
Fig. 53h
Fig. 53 j–l: Low- (Fig. 53 j), intermediate(Fig. 53 k) and high-power (Fig. 53 l) histologic images show a myxoid stroma, rich
vascularization with branching capillaries,
and fat cells of varying sizes, a typical histologic picture of a myxoid liposarcoma.
Fig. 53i
Comment
The rarely seen liposarcoma is radiopaque
with no pathognomonic imaging features.
Practice in Analyzing Circular/Oval Tumors
Fig. 53j
Fig. 53k
Fig. 53l
97
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IV Circular/Oval Lesions
54
Fig. 54: Detailed mammogram in the CC
projection; 6 × 4 cm lobulated tumor without associated calcifications.
Analysis
Form: oval-shaped, lobulated
Contour: many short spicules make the contour ill defined
Density: high-density radiopaque
Size: 6 × 4 cm
Conclusion
Mammographically typical malignant tumor.
Fig. 54
Histology
Invasive ductal carcinoma.
Follow-up
The patient died 2 years and 8 months later
of metastatic breast carcinoma.
55
Fig. 55: Left breast, CC projection. There is a
tumor in the medial half of the breast, near
the chest wall.
Analysis
Form: oval, lobulated
Contour: sharply defined
Density: low-density radiopaque
Size: 3.5 × 2.5 cm
Conclusion
Mammographically benign tumor.
Comment
The most frequently occurring mammographically benign circular/oval lesions are
cyst, fibroadenoma, and papilloma. Ultrasound examination with ultrasound-guided
needle biopsy provides excellent differential diagnosis.
Histology
Fibroadenoma.
Fig. 55
Practice in Analyzing Circular/Oval Tumors
99
56
A 49-year old woman felt a tumor in the
lower portion of her left breast.
Mammography and Ultrasound
Fig. 56 a: A large solitary, lobulated, radiopaque oval lesion with no associated calcifications is seen in the detail picture of the
left MLO projection.
Fig. 56 b, c: Ultrasound examination reveals
a cystic tumor with intracystic growth.
Histology
Fig. 56 d, e: Large-section histology images
of the cyst containing several intracystic
tumors.
Fig. 56 f–i: 30 × 20 mm grade 1 intracystic
papillary cancer with no signs of invasion.
The tumor is ER and PR positive, c-erb-B-2
negative.
Fig. 56b
Fig. 56a
Fig. 56c
Fig. 56d–i e
100
IV Circular/Oval Lesions
Fig. 56d
Fig. 56e
Fig. 56f
Fig. 56g
Fig. 56h
Fig. 56i
V Stellate/Spiculated Lesions
and Architectural Distortion
Subgross (3D) histology images
Stellate invasive ductal carcinoma
A radial scar
An additional radial scar
An additional invasive ductal carcinoma
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Stellate/Spiculated Lesions and Architectural Distortion
The majority of breast carcinomas have the
mammographic appearance of a radiating
structure, either a definite stellate/spiculated lesion or architectural distortion with
no central tumor mass. The most typical
mammographic appearance of breast carcinoma is a stellate lesion, i. e. a solid central
tumor mass surrounded by a radiating
structure. Perception of these lesions may
be difficult, especially when they are small.
Although mammographic differentiation of
breast carcinoma from other stellate lesions
may be highly accurate, definitive diagnosis
comes from histology. Architectural distortion without a central tumor mass is a less
common sign of malignancy. Its perception
requires familiarity with the full variety of
normal breast parenchymal structure and
an understanding of how pathologic processes produce distortion. Architectural distortion without a central tumor mass may
be caused by a number of malignant or benign diseases, as listed below.
Malignant Diseases
• Invasive ductal carcinoma NOS (not otherwise specified)
• Invasive lobular carcinoma
• Neoductgenesis
Benign Diseases
• Radial scar
• Traumatic fat necrosis
When viewing stellate/spiculated lesions
and architectural distortion, proper analysis
of both the central portion and the radiating
structure itself will lead to the correct diagnosis. Spot compression microfocus magnification views are of great value in evaluating these mammographic signs.
Analysis of the central portion may show
either a distinct mass or oval/circular radiolucent areas. Each is associated with its own
characteristic surrounding radiating structure, resulting in one of two mammographic images that are diagnostic:
• “white star” (Fig. XXI): sharp, dense, fine
lines of variable length radiating in all
directions from a distinct central tumor
mass. This is the typical picture of invasive ductal and tubular carcinoma (Cases
57, 58, 59, 60, 65, 70, 71, 72, 73, 85). The
larger the central tumor mass, the longer
the spicules. These are composed of dense
collagen, and are seen on the mammogram as high-density radiopaque linear
structures. They occasionally contain in
situ or invasive carcinoma, indistinguishable from those containing only collagen.
Fig. XXI Diagrammatic illustration of invasive ductal carcinoma: the larger the central tumor mass,
the longer the spicules.
The spicules may reach the skin or
muscle, causing retraction and localized
skin thickening, which is often present in
large or superficial invasive ductal carcinomas (Case 60). Skin changes may also
be present in traumatic fat necrosis, especially postoperatively (Cases 68, 69).
Malignant-type calcifications are commonly associated with a white star
• “black star” (Fig. XXII): a radiating structure consisting of linear densities interspersed with linear radiolucencies; this
picture, combined with the circular or
oval radiolucent areas at the center,
dominates the mammographic image
(“black star”) (Case 81). These are the
characteristic features of a radial scar
(sclerosing duct proliferation/hyperplasia), which consists of proliferating ducts
with periductal elastosis, arranged in a
radiating fashion (Cases 61, 62, 63, 64, 66,
67, 81, 82, 83). Radial scars vary in appearance from one mammographic projection to the other. Each view may thus
give a somewhat different picture. A
similar mammographic appearance can
occasionally be seen in traumatic fat necrosis (Case 68). This mammographic
image of a black star is unlike the radiating structure of an invasive cancer. A ra-
Stellate/Spiculated Lesions and Architectural Distortion
103
dial scar is never associated with skin
thickening or retraction and there is a
striking difference between the distinct
mammographic findings and the nearly
complete absence of a palpable lesion, no
matter how large or superficial it may be.
Ultrasound examination assists in the
differential diagnosis because the center
of a radial scar shows cystic dilatation of
the proliferating ducts, unlike the typical
dense, acoustic shadowing of an invasive
carcinoma.
Comment
Fig. XXII Illustration of the mammographic appearance of a radial scar.
The mammographic appearance of the
small, usually nonpalpable invasive ductal
and tubular carcinomas may differ from
the typical appearance of a white star:
• the earliest detectable phase of an invasive carcinoma may present as a nonspecific asymmetric density lacking the typical radiating structure of a tumor, but it
also lacks the terminal duct lobular units
(TDLUs) and other building blocks of the
normal breast parenchyma. When this
nonspecific asymmetric density is found
in any of the four “forbidden areas” described in Chapter II, it raises the suspicion of malignancy and requires further
workup (Cases 74, 76, 78). Higher-resolution magnification mammography images may reveal a small central tumor
mass not seen in the initial mammographic images, and breast ultrasound can
be very effective in confirming the malignant nature of the asymmetric density
• the asymmetric density may consist of a
lace-like, fine reticular structure which
causes parenchymal distortion. This may
be the only change leading to detection
(Case 75).
Architectural distortion without a central
tumor mass may also be caused by the following diseases:
• invasive lobular carcinoma, classic type.
Due to the absence of E-cadherin, the
cancer cells spread along the existing
breast structures, such as fibrous strands
and ducts, which will eventually cause a
fine, web-like/reticular pattern, distorting
the normal breast structure (Case 83)
• neoductgenesis. Certain subtypes of
breast cancer are characterized by formation of new, duct-like structures, resulting in an unnaturally high concentration of these abnormal, tumor-filled ducts
within a limited volume. The mammo-
104
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graphic image shows an asymmetric
density with architectural distortion,
with or without associated malignanttype calcifications (Case 84). When
present, the most characteristic calcifications in these cases are the so-called
casting type—long, branching, fragmented, or dotted calcifications (Chapter
VI)1
• radial scar (sclerosing duct hyperplasia).
This benign, rarely palpable lesion may be
mistakenly diagnosed as carcinoma; conversely, invasive lobular carcinoma may
occasionally give the mammographic impression of a radial scar. Mammography
screening has brought attention to this
lesion. A prevalence of 0.9 per 1000 was
observed in our prevalent screening material. The occurrence of this cancer-imitating lesion makes it an important practical problem, since about one-third of
these lesions are associated with cancer in
situ or tubular carcinoma.2 Furthermore,
the exact nature of this lesion is a subject
of some controversy among pathologists
and it has been given many different
names3–10
• traumatic fat necrosis. Fat necrosis following trauma, including surgery, can
result in at least two basic types of
mammographic image—a circular/oval
lesion (hematoma developing into an oil
cyst) and a stellate lesion. Calcification
may be associated with either of these
(Chapter VI). Relevant patient history
contributes to the diagnosis. The presence
of ecchymosis is useful. The characteristic
mammographic appearance, when the
traumatic fat necrosis results in a stellate
lesion, is as follows (Cases 66, 68, 84):
— center of the lesion: there is seldom a
distinct mass unless the necrosis has
resulted from secondary healing. Typically, translucent areas corresponding
to small oil cysts are seen in the central
portion. The older the lesion, the less
solid the center (Cases 68, 84)
— radiating structure: varies with the
projection, particularly in spot compression views. Spicules are fine and of
low density
— localized skin thickening and retraction
may be present (Cases 68, 69, 84).
Note: The combination of patient history,
physical examination and mammographic
findings is necessary to arrive at the correct
diagnosis.
Strategy
Although the definitive diagnosis of architectural distortion on the mammogram requires histologic examination, the preoperative differentiation between malignant
stellate lesions and radial scars based on
mammographic signs will have a significant
influence upon the management of these
lesions.
In stellate lesions suspicious for malignancy (“white star”), preoperative needle
biopsy should establish the diagnosis and
will greatly facilitate the treatment planning (one-stage operation, sentinel node/
axillary dissection, etc.). On the contrary,
the use of preoperative needle biopsy of
radial scars (“black star”) carries a considerable risk of overdiagnosis/underdiagnosis
and should be avoided. Complete surgical
removal and thorough histological examination should be carried out when a radial
scar is suspected.
The diagnosis of traumatic fat necrosis
can be established by the patient’s history,
characteristic mammographic findings, and,
when necessary, by large-core needle biopsy.
Stellate/Spiculated Lesions and Architectural Distortion
Key Case
57
This case is meant to demonstrate the characteristics of a typical malignant stellate
tumor. It is recommended that radiologists
refer to this case while analyzing other stellate lesions.
The presence of a central tumor mass with
associated spicules is typical of malignant
stellate tumors. The spicules are dense and
sharp, radiating from the tumor surface,
usually not bunched together. When they
extend to the skin or areolar region they
cause retraction and local thickening. The
larger the tumor mass, the longer the spicules (see Fig. XXI).
Fig. 57a
Fig. 57b
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Stellate/Spiculated Lesions and Architectural Distortion
Practice in Analyzing
Stellate/Spiculated
Lesions and Architectural Distortion on the
Mammogram
(Cases 58–85)
58
A 73-year-old asymptomatic woman. First
screening study.
Physical Examination
No palpable tumor.
Mammography
Fig. 58 a: Right breast, mediolateral oblique
(MLO) projection. A small tumor shadow is
seen at coordinate A1.
Fig. 58 b: Right breast, craniocaudal (CC)
projection. The tumor is seen at coordinate
A1. There are no associated calcifications.
Fig. 58 c: Magnification view, MLO projection.
Analysis
Form: small tumor mass surrounded by spicules
Size: 4 × 4 mm
Conclusion
Mammographically malignant tumor.
Histology
Infiltrating ductal carcinoma, size 4 × 4 mm.
No axillary metastases.
Fig. 58 d: Specimen photograph.
Fig. 58 e: Overview of the tumor with staining for elastic fibers (12.5 ×).
Follow-up
The woman died 1 year and 11 months later
from pulmonary embolism, aged 75 years.
There was no evidence of breast cancer at
the time of death.
Fig. 58b
Fig. 58a
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 58c
Fig. 58d
Fig. 58e
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59
A 63-year-old asymptomatic woman. First
screening examination.
Physical Examination
No palpable tumor.
Mammography
Fig. 59 a: Left breast, MLO projection.
Fig. 59 b: Magnification view in the MLO
projection.
Fig. 59 c: Left breast, CC projection. A stellate
tumor is seen in the upper inner quadrant,
7 cm from the nipple. There are no associated calcifications.
Conclusion
This tumor has the typical mammographic
appearance of a malignant stellate breast
tumor: solid center, radiating spicules
(“white star”).
Fig. 59a
Histology
Invasive ductal carcinoma. Maximum diameter 7 mm. No lymph node metastases.
Fig. 59 d: Specimen photograph.
Follow-up
The woman died 8 years and 5 months later
from colon cancer. At the time of death,
there was no evidence of metastatic breast
cancer.
Fig. 59c
Fig. 59d
Fig. 59b
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
60
An 89-year-old woman with a 1-year history of a slowly growing tumor in the right
breast.
Physical Examination
A large, obviously malignant tumor in the
right breast.
Mammography
Fig. 60 a, b: Right breast, MLO and CC projections. Centrally located, large (5 cm diameter) stellate tumor. The nipple and areola
are retracted. The skin is thickened and retracted over the lower and outer portions of
the breast.
Comment
This is an illustrative example of an advanced stellate malignant breast tumor
with a large central tumor mass and radiating spicules that retract the areola and skin.
Histology
Infiltrating ductal carcinoma. The tumor infiltrates the lymph vessels.
Follow-up
The patient died 1 year and 6 months later
of metastatic breast carcinoma.
Fig. 60b
Fig. 60a
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61
A 61-year-old asymptomatic woman. First
screening study.
Mammography
Fig. 61 a, b: Right (a) and left (b) breasts,
MLO projections. Compare the lower halves
of the right and left breasts. In the lower half
of the right breast there is architectural distortion centered at coordinate A1.
Physical Examination
No palpable tumor, no history of trauma.
A
Fig. 61a
1
Fig. 61b
Fig. 61 c: Right breast, CC projection.
Fig. 61 d: Right breast, microfocus magnification view, MLO projection. Compare
Fig. 61 a with Fig. 61 c, d. Observe how the
lesion has a different appearance in each
projection.
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Analysis
Form: radiating structure with no central
tumor mass; the magnification view in particular shows the small radiolucencies at the
center of the lesion; the radiating structure
is formed by long slightly curved linear densities interspersed with radiolucent adipose
tissue
Size: the lesion occupies much of the lower
outer breast quadrant
Conclusion
This mammographic appearance is typical
of a radial scar. The diagnosis is supported
by the lack of palpatory findings. No further
diagnostic procedures are indicated. In fact,
needle biopsy is contraindicated (see
p. 104). The next step should be open surgical biopsy followed by careful histologic examination.
Fig. 61c
Histology
Radial scar (sclerosing duct hyperplasia). No
evidence of malignancy.
Fig. 61d
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62
A 63-year-old asymptomatic woman. First
screening study.
Physical Examination
No palpable tumor, no history of previous
trauma.
Mammography
Fig. 62 a, b: MLO and CC projections. A large
area with architectural distortion is seen
4 cm from the nipple. The mammographic
appearance of the lesion changes with the
projection. The two hollow, benign-type
calcifications are not associated with the
lesion.
Analysis
An invasive ductal carcinoma of this size
would have a large, solid central tumor
mass. Instead, there are central radiolucencies in both projections, particularly in
Fig. 62 a. The radiating structure consists of
long, thick, drooping linear densities intervening with radiolucencies. The mammographic image is unlike the straight speculations of an invasive breast cancer. Unlike
large breast cancers, this lesion was not palpable, nor was there skin thickening or retraction.
Fig. 62a
Conclusion
Typical mammographic and clinical picture
of a radial scar. Complete surgical removal is
recommended without preoperative needle
biopsy (see p. 104).
Fig. 62b
Histology
Radial scar (sclerosing duct hyperplasia)
without associated epithelial cell proliferation. No evidence of malignancy.
Fig. 62 c: Operative specimen photograph.
Comment
An invasive ductal carcinoma similar in size
to Cases 61–64 would be palpable and
would have a large, dense, homogeneous
central tumor mass dominating the picture
(compare Case 60 with Cases 61–64).
Fig. 62c
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
63
Asymptomatic 69-year-old woman. First
screening study.
Physical Examination
No history of trauma, no palpable tumor.
Mammography
Fig. 63 a: Left breast, detailed view of the
MLO projection. There is a large radiating
structure in the upper half of the breast.
Fig. 63 b, c: Left breast, microfocus magnification views, MLO and CC projections.
Analysis (Best from the Microfocus Magnification Views)
No solid tumor center is demonstrable in
this radiating structure. The radiating structure consists of thick collections of linear
densities bunched together. Alternating
with them are radiolucent linear structures
parallel to these strands. There are no associated calcifications.
Fig. 63a
Conclusion
Typical mammographic appearance of a radial scar.
Comment
Even with such a large, superficial lesion, no
tumor could be palpated. This supports the
diagnosis of a radial scar.
Histology
Radial scar. No evidence of malignancy.
Fig. 63c
Fig. 63b
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64
Age 52 years, referred for pain in the right
breast.
Physical Examination
No palpable tumor in either breast.
Mammography
Fig. 64 a: Right breast, MLO projection. 7 cm
from the nipple at coordinate A1 there is a
radiating structure.
Fig. 64 b: Right breast, CC projection. The
radiating structure is seen at coordinate A1.
Fig. 64 c: Right breast, enlarged view of the
lateromedial (LM) projection.
A
Analysis
No solid tumor center. The appearance of
the lesion changes remarkably with the projection. The radiating structure consists of
thick linear radiopaque densities alternating with linear translucencies.
Conclusion
Typical mammographic appearance of a radial scar, the diagnosis being supported by
the absence of palpatory findings. Complete
surgical removal is the treatment of choice.
1
Fig. 64a
Histology
Radial scar (sclerosing duct hyperplasia). No
evidence of malignancy.
A
1
Fig. 64b
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 64c
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65
Asymptomatic 63-year-old woman. First
screening examination.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 65 a: Right breast, MLO projection.
Fig. 65 b: Right breast, CC projection.
Fig. 65 c: Spot microfocus magnification image in the CC projection.
A stellate tumor is seen 6 cm from the nipple in the lateral half of the breast. There are
no associated calcifications.
Conclusion
This is a typical mammographic picture of a
small infiltrating carcinoma: the solid tumor mass is surrounded by radiating spicules. Since > 90 % of invasive carcinomas
smaller than 10 mm are of histologic grade
1 or 2, fine needle aspiration biopsy may not
lead to conclusive diagnosis of malignancy.
Ultrasound-guided core biopsy (a single
shot through the lesion) provides sufficient
preoperative information for treatment
planning.
Histology
Tubular carcinoma. Size 6 × 6 mm. No axillary metastases.
Fig. 65 d: Overview of the tumor. (hematoxylin and eosin [H&E], 12.5 ×).
Fig. 65 e: Detailed view of the tubular carcinoma with a grade 1 in situ component.
(H&E, 200 ×).
Fig. 65a
Follow-up
The patient died 6 years and 9 months later
from acute myocardial infarction. There was
no evidence of breast cancer at the time of
death.
Fig. 65b
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
117
Fig. 65c
Fig. 65d
Fig. 65e
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Stellate/Spiculated Lesions and Architectural Distortion
66
Asymptomatic woman, aged 66 years. First
screening study.
Physical Examination
No history of trauma, no palpable tumor.
Mammography
Fig. 66 a: Right breast, MLO projection:
there is a radiating structure 9 cm from the
nipple. In addition, calcifications are scattered throughout the breast.
Analysis of the Tumor
Form: radiating structure with no central
tumor mass; instead, the center is radiolucent; the radiating structure contains thick,
long radiopaque densities like sheaves of
wheat
Size: large, difficult to determine, approximately 5 × 4 cm
Conclusion
The combination of the above-mentioned
mammographic signs is characteristic of a
radial scar.
Analysis of the Calcifications
Distribution: along the course of the ducts
Form: elongated, smooth-bordered, some
are needle-like
Density: high, uniform
Size: within dilated ducts
Conclusion
Typical picture of calcifications resulting
from plasma cell mastitis.
Fig. 66a
Comment
The benign lesion and benign-type calcifications are unrelated to each other.
Although the mammographic picture is
characteristic of a radial scar, detailed histologic examination is necessary. The tumor
was excised in toto.
Fig. 66 b: Specimen photograph. Note the
thick radiating tissue strands. There appears
to be a hole in the center of the lesion corresponding to the radiolucent center of the
lesion on the mammogram.
Fig. 66b
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Histology
Radial scar. No evidence of malignancy.
Fig. 66 c: Right breast (same case 6 months
later). A palpable tumor has developed at
the site of operation. MLO projection: the
palpable tumor corresponds to the large
radiating structure on the mammogram.
This case was reoperated before the advent
of percutaneous core needle biopsy.
Histology
Traumatic fat necrosis. No evidence of malignancy.
Follow-up
The woman died 8 years later of septicemia,
aged 74 years. At the time of death there
was no evidence of breast cancer.
Fig. 66c
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67
Asymptomatic 63-year-old woman, screening case.
Physical Examination
A hard, freely movable lump was palpated
in the upper inner quadrant of the right
breast. No history of trauma.
Mammography
Fig. 67 a, b: Right breast, MLO and CC projections. There is a large radiating structure
in the upper inner quadrant of the breast,
with associated calcifications.
Fig. 67 c: Spot magnification view, CC projection.
Analysis
The radiating structure consists of collections of thick, linear radiopacities. At the
center of the large lesion, coarse calcifications are seen.
Conclusion
This large region of architectural distortion
did not cause skin changes, despite its
superficial location. This radiating structure
differs from that seen with malignant tumors of a similar size. The mammographic
image is consistent with a radial scar. The
associated calcifications are unusually large,
coarse, and of uniformly high density; they
are of the benign type.
Histology
Radial scar (sclerosing duct hyperplasia). No
evidence of malignancy.
Fig. 67a
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 67b
Fig. 67c
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Stellate/Spiculated Lesions and Architectural Distortion
68
A 45-year-old woman. History of repeated
aspirations from a large cyst in the right
breast.
Mammography
Fig. 68 a: Right breast, CC projection. The
large circular lesion in the medial half of
the breast corresponds to a cyst. The patient
requested surgical removal of the cyst.
Fig. 68 b: Right breast, CC projection,
6 months after surgery. A large radiating
structure is seen at the site of operation.
There are no associated calcifications.
Fig. 68 c: Right breast, CC projection, 2 years
following surgery. The radiating structure is
smaller.
Fig. 68a
Analysis
Center of the lesion (Fig. 68 c): circular and
oval translucencies are demonstrable (arrows)
Radiating structure: much less apparent
than in the previous study
Comment
This case demonstrates the typical appearance and regression of traumatic (postsurgical) fat necrosis.
Fig. 68b
Fig. 68c
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
69
A 67-year-old-woman. First screening
study. History of right breast surgery 25
years earlier, for a benign lesion. The skin
retraction and the thick scar at the site of
operation had remained unchanged for
many years.
Mammography
Fig. 69 a, b: Right breast, MLO and detailed
view of the CC projection. There is architectural distortion in the lower outer quadrant,
with central calcifications and associated
focal skin thickening and retraction.
Analysis
Central portion of the architectural distortion: there is a definite tumor mass, which
also contains lucent areas. The appearance
of the tumor changes with the projection
Radiating structure: on the CC projection
(Fig. 69 b), linear radiolucencies form part
of the lesion
Calcifications: coarse, highly dense, centrally located within a lucent area, mammographically of the benign type
Comment
A radiating structure on the mammogram
that changes its appearance with projection
and contains central translucencies (either
linear, oval or circular) is characteristic of
one of the cancer-mimicking benign
lesions—either radial scar or traumatic fat
necrosis. The history may help in differentiation, as in this case.
Fig. 69a
Histology
Foreign body granuloma.
Fig. 69b
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70
Asymptomatic 70-year-old woman. First
screening examination.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 70 a–c: Voluminous right breast which
required three 18 × 24 cm films for one MLO
projection.
Fig. 70 d: Right breast, CC projection. A small
tumor is seen at coordinate A1 in these four
mammograms.
Fig. 70 e: Microfocus magnification view, CC
projection. The tumor is seen at coordinate
A1.
Analysis
Central tumor mass with long radiating spicules. No associated calcifications. Mammographically malignant tumor.
Histology
Infiltrating ductal carcinoma, size 7 mm. No
axillary lymph node metastases.
Comment
There are a number of other radiopaque,
poorly defined parenchymal structures in
this breast (adenosis). Only the tumor,
with its radiating structure, is abnormal.
Follow-up
The woman died 13 years later from myocardial infarction, aged 83 years. There was
no evidence of breast cancer.
A
Fig. 70a
1
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 70b
Fig. 70c
1
Fig. 70e
Fig. 70d
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71
A 60-year-old woman.
Physical Examination
A palpable tumor was noted in the lateral
portion of the left breast, clinically suspicious for malignancy.
Mammography
Fig. 71 a, b: Right and left breasts, MLO projections.
Fig. 71 c: Left breast, CC projection.
Fig. 71 d, e: Spot compression with microfocus magnification, CC projection. At coordinate A1 in Fig. 71 b, c there is a 2 cm stellate tumor. There are no associated calcifications.
Analysis
(Best on the spot compression views.)
Stellate tumor with a central tumor mass,
size 15 × 15 mm. The spicules are short. The
overlying parenchyma is dense and obscures much of the tumor.
Conclusion
Mammographically malignant tumor.
A
Fig. 71a
Fig. 71b
1
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Comment
This case is a problem in perception rather
than in analysis. The tumor can be detected
on the MLO projection by oblique masking,
caudal aspect (see Chapter II). Retraction of
the posterior parenchymal border on the CC
projection (Fig. 71 c) produces the “tent
sign” (see Chapter II).
Histology
Infiltrating ductal carcinoma. No axillary
lymph node metastases.
Fig. 71c
Fig. 71d
Fig. 71e
127
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72
Asymptomatic 71-year-old woman. First
screening examination.
Physical Examination
No palpable tumor.
Mammography
Fig. 72 a, b: Right and left breasts, MLO projections. Normal right breast. At coordinate
A1 there is a small stellate tumor with no
associated calcifications.
Fig. 72 c: Left breast, CC projection.
Fig. 72 d, e: Spot compression microfocus
magnification views, CC and LM projections.
Fig. 72 f: Operative specimen.
Analysis
Form: stellate; small tumor mass with surrounding spicules
Size: less than 10 mm
Conclusion
Mammographically malignant tumor.
Fig. 72a
Histology
Infiltrating ductal carcinoma. No axillary
lymph node metastases.
Fig. 72 g: Overview of the tumor (H&E,
12.5 ×).
Comment
This case represents a problem in perception, which can be solved by horizontal
masking, cranial aspect (see Chapter II).
Follow-up
The woman was still alive 21 years later at
the age of 92 years, with no evidence of
breast cancer.
Fig. 72c
Fig. 72b
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 72d
Fig. 72f
Fig. 72g
Fig. 72e
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73
Asymptomatic 68-year-old woman. First
screening study.
Physical Examination
With knowledge of the mammogram, a tumor could be vaguely palpated in the upper
outer quadrant of the right breast.
Mammography
Fig. 73 a: Right breast, MLO projection. The
breast parenchymal contour protrudes at
coordinate A1, forming an outline that is
distinctly different from that of the contralateral breast. There are coarse calcifications not associated with the tumor, 4 cm
from the nipple.
Fig. 73 b: Left breast, MLO projection. No
mammographic abnormality.
Fig. 73 c: Right breast, detailed view of the
CC projection. The tumor, located at coordinate A1, causes a retraction of the parenchymal contour.
A
Fig. 73a
1
Fig. 73b
Fig. 73 d: Right breast, microfocus magnification view, MLO projection. There is a stellate tumor with a distinct central mass, size
approximately 10 mm, surrounded by long,
straight spicules.
Conclusion
Typical mammographic appearance of a
stellate malignant tumor. The calcifications
4 cm from the nipple are coarse and of the
benign type, typical of a hyalinized fibroadenoma.
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Histology
Infiltrating ductal carcinoma, size 10 mm.
No axillary lymph node metastases.
Fig. 73 e: Overview of the tumor using an
immunohistochemical stain for estrogen receptors. More than half of the nuclei express
receptor positivity through brown staining.
(12.5 ×).
Fig. 73 f: Detailed view of the spiculated
contour. The spicules contain grade 1 ductal
carcinoma in situ, which also stains posiA
tively for estrogen receptors (100 ×).
Fig. 73 g: Higher magnification of one spicule (200 ×).
Fig. 73 h: The invasive component of the tumor (200 ×).
Follow-up
The patient was still alive 20 years later,
aged 88 years, with no evidence of breast
cancer.
Fig. 73c
Fig. 73d
Fig. 73e
1
Fig. 73f–h e
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Fig. 73f
Fig. 73g
Fig. 73h
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74
Asymptomatic 57-year-old woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Fig. 74 c: Left breast, CC projection.
Fig. 74 d: Spot compression microfocus
magnification view in the CC projection.
Small, ll-defined circular tumor mass, mammographically malignant.
Histology
Infiltrating ductal carcinoma, size less than
10 mm. No axillary metastases.
Fig. 74 e: Overview of the tiny tumor (H&E,
12.5 ×).
Mammography
Fig. 74 a, b: Right and left breasts, MLO projections. A small tumor is seen at coordinate
A1 in the upper outer quadrant of the left
breast.
Fig. 74a
133
Comment
This tumor is difficult to locate on the MLO
projection. Oblique masking helps reveal
the tumor (Fig. XVIb, Chapter II p. 9. The
density seen at coordinate A2 corresponds
to the so-called desmoplastic reaction (connective tissue proliferation in the vicinity of
the malignant tumor).
Follow-up
The woman was still alive 19 years later,
with no evidence of breast cancer.
Fig. 74b
Fig. 73c–e e
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Fig. 74c
Fig. 74d
Fig. 74e
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75
A 65-year-old asymptomatic woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 75 a, b: Left breast, MLO and CC projections.
A small, non-specific structure is seen in the
upper outer quadrant, 9 cm from the nipple,
at coordinate A1.
Fig. 75 c, d: Microfocus magnification views,
MLO and CC projections.
Analysis
Lace-like radiating structure, less than
10 mm in size.
Mammographic diagnosis: malignant lesion.
Fig. 75 e: Operative specimen photograph.
Histology
Infiltrating ductal carcinoma, size 9 mm. No
axillary lymph node metastases.
Follow-up
The patient died 9 years later of renal failure, aged 74 years. There was no evidence of
breast cancer at the time of death.
Fig. 75a
Fig. 75b
Fig. 75c–e e
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V
Fig. 75c
Fig. 75d
Fig. 75e
Stellate/Spiculated Lesions and Architectural Distortion
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
76
Fig. 76 e: Right breast. Enlarged view in the
mediolateral projection. The tumor is located at coordinate A1.
Asymptomatic 73-year-old woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 76 a, b: Right and left breasts, MLO projections. There is a stellate lesion at coordinate A1 in the right breast.
Fig. 76 c: Right breast, CC projection. A tumor is seen at coordinate A1.
Fig. 76 d: Spot compression view in the CC
projection.
Analysis
Form: stellate; small tumor mass with surrounding spicules; no associated calcifications
Size: less than 10 mm
Conclusion
Mammographically malignant tumor.
137
Histology
Infiltrating ductal carcinoma, maximum
diameter 10 mm. No axillary metastases.
Fig. 76 g: Overview of the tumor (H&E,
12.5 ×).
Follow-up
The woman died 12 years later from myocardial infarction, aged 85 years. There was
no evidence of breast cancer at the time of
death.
Comment
The smaller the stellate tumor, the greater
the difficulty in perception. The tumor can
be detected on the MLO projection using
oblique masking (see Chapter II).
Fig. 76 f: Operative specimen photograph.
A
Fig. 76a
1
Fig. 76b
Fig. 76c–g e
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A
Fig. 76c
Fig. 76d
1
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
A
Fig. 76e
Fig. 76f
Fig. 76g
1
139
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77
A 61-year-old asymptomatic woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 77 a: Left breast, MLO projection. At coordinate A1 there is parenchymal distortion.
Fig. 77 b: Left breast, CC projection. There is
architectural distortion located centrally,
6 cm from the nipple.
Fig. 77 c: Left breast, microfocus magnification view in the CC projection.
Fig. 77 d: Operative specimen radiograph.
A
Analysis
No definite central tumor mass is demonstrable on the preoperative mammograms,
but a tiny tumor mass can be seen on the
operative specimen radiograph. Long, fine
spicules form the radiating structure. No
associated calcifications are demonstrable.
Conclusion
The overlying dense parenchyma obscures
the tiny central tumor mass. The long, radiating spicules distort the normal breast
structure, enabling detection of the tumor.
Histology
Infiltrating ductal carcinoma. No axillary
metastases.
Fig. 77a
Follow-up
The woman was still alive 19 years later.
Fig. 77b
1
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 77c
Fig. 77d
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78
A 64-year-old asymptomatic woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 78 a, b: Right and left breasts, MLO projections. At coordinate A1 in the left breast
there is a small, nonspecific asymmetric
density. Normal right mammogram.
Fig. 78 c: Left breast, CC projection. The
asymmetric density is seen at coordinate
A1.
Fig. 78 d: Left breast, spot-magnification
view in the CC projection. The nonspecific
asymmetric density corresponds to a tiny,
ill-defined circular tumor mass, superimposed over the calcified artery.
A
Fig. 78a
Fig. 78b
1
A
Analysis
Form: ill-defined solitary tumor mass, best
seen in the spot-magnification view
Size: less than 10 mm
Conclusion
Mammographically malignant tumor.
Histology
Infiltrating ductal carcinoma, maximum
diameter 7 mm. No axillary lymph node
metastases.
Follow-up
The patient died 12 years later from acute
heart failure. At the time of death, there was
no evidence of breast cancer.
1
Fig. 78c
Fig. 78d
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143
79
A
A 70-year-old asymptomatic woman. First
screening examination.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 79 a: Right breast, MLO projection. A
small, non-specific density is seen at coordinate A1.
Fig. 79 b: Right breast, CC projection. The
lesion is seen at coordinate A1.
Fig. 79 c: Spot magnification view of the tumor in the MLO projection.
Analysis
Form: ill-defined, solitary tumor mass
Size: less than 1 cm
Conclusion
An ill-defined, non-specific tumor mass located in one of the four “forbidden areas”
(see Chapter II) is highly suspicious for malignancy.
Fig. 79a
1
A
Fig. 79b
1
Fig. 79c
Fig. 79d, e e
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Histology
Infiltrating ductal carcinoma, size 6 × 6 mm.
No axillary lymph node metastases.
Fig. 79 d: Overview of the tumor (H&E,
12.5 ×).
Fig. 79 e: Detailed view of the invasive carcinoma (H&E, 200 ×).
Follow-up
The patient returned to her native country,
where she died 4 years and 10 months later
of unknown causes, aged 74 years.
Fig. 79d
Fig. 79e
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80
A 44-year-old woman, referred for mammography for a palpable tumor in the upper
outer quadrant of the left breast.
Physical Examination
2 × 2 cm hard lump in the upper outer quadrant of the left breast. No skin changes. Suspicious for malignancy.
A
Mammography
Fig. 80 a: Left breast, MLO projection. There
is parenchymal contour retraction (see Fig.
XIXa) at coordinate A1. No associated calcifications are seen.
Fig. 80 b: Left breast, CC projection. There is
architectural distortion at coordinate A1,
with an associated tent sign (see Fig. XVIIIc).
Fig. 80 c: Left breast, spot magnification
view, CC projection.
Analysis (Best on the Spot Compression
View)
Stellate tumor with a central tumor mass
surrounded by numerous spicules. Mammographically malignant tumor.
Histology
Infiltrating ductal carcinoma with axillary
lymph node metastases.
Fig. 80 d: Low-power view of the invasive
tumor, with a poorly differentiated in situ
component containing amorphous calcifications (H&E, 40 ×).
Fig. 80a
1
Follow-up
The patient died 4 years later, aged 48 years,
from breast cancer with hepatic and skeletal metastases.
A
Fig. 80b
1
Fig. 80c, d e
146
V
Fig. 80c
Fig. 80d
Stellate/Spiculated Lesions and Architectural Distortion
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
81
A 46-year-old asymptomatic woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 81 a: Left breast, MLO projection. A radiating structure is seen 8 cm from the nipple in the upper half of the breast.
Fig. 81 b: Left breast, microfocus magnification view of the lesion.
Analysis
Instead of a solid, central tumor mass, as is
typically seen with breast cancer, a large
oval translucency is found near the center
of the lesion. The radiating structure is
formed by alternating radiopaque and radiolucent linear structures, also unlike the
appearance of infiltrating breast cancer. The
associated calcifications are very faint.
Fig. 81a
Conclusion
Typical mammographic appearance of a radial scar.
Histology
Radial scar (sclerosing duct hyperplasia). No
associated malignancy.
Fig. 81b
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82
A 42-year-old asymptomatic woman. First
screening examination.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 82 a, b: Right and left breasts, MLO projections. At coordinate A1, in the right
breast, there is a small non-specific asymmetric density.
Fig. 82 c: Right breast, CC projection: the
asymmetric density with radiating structure is located at coordinate A1.
Fig. 82 d: Right breast, microfocus magnification view, CC projection.
Histology
Fig. 82 f: Radial scar (sclerosing duct hyperplasia) associated with a slight degree of
epithelial cell proliferation (H&E, 40 ×). No
evidence of malignancy.
Analysis
The radiating structure lacks a central tumor mass, consisting of radiopaque linear
densities. There are no associated calcifications.
Comment
This lesion is difficult to perceive and also
difficult to differentiate from breast cancer.
Oblique masking, cranial aspect, helps with
perception (Fig. 82 e).
Conclusion
Differentiation between a small stellate malignant tumor and a radial scar cannot be
reliably made using imaging methods alone.
A
Fig. 82a
1
Fig. 82b
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149
A
Fig. 82c
1
Fig. 82d
Fig. 82e, f e
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Stellate/Spiculated Lesions and Architectural Distortion
Fig. 82e
Fig. 82f
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
83
This 86-year-old woman presented with a
large palpable tumor in her right breast. The
nipple–areola complex and skin overlying
the tumor were retracted.
Fig. 83a
151
Mammography
Fig. 83 a, b: Right (a) and left (b) breasts,
details of the MLO projections. The right
breast is smaller than the left because of a
large, palpable tumor that has “shrunk it.”
The huge region of architectural distortion
occupies most of the right breast. There are
coarse, benign-type calcifications in both
breasts (these are entirely calcified fibroadenomas).
Fig. 83b
Fig. 83c–k e
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Stellate/Spiculated Lesions and Architectural Distortion
Fig. 83 c, d: Right (c) and left (d) CC projections. The large architectural distortion
drastically alters the appearance of the right
breast. Neither a distinct tumor mass nor
microcalcifications are seen associated
with the architectural distortion.
Fig. 83c
Fig. 83 e, f: Photographic magnification of
the upper half of the right breast with the
architectural distortion (e). Hand-held ultrasound (f): several irregular hypoechoic
lesions are demonstrable.
Fig. 83d
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 83e
153
Fig. 83f
Fig. 83g–k e
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Stellate/Spiculated Lesions and Architectural Distortion
Conclusion
The physical examination findings and the
mammographic and ultrasound examinations suggest that the architectural distortion corresponds to the classic type of invasive lobular carcinoma in the right breast.
Fig. 83 g: Ultrasound-guided 14-g core biopsy.
Histology
Fig. 83 h, i: Histology images (H&E): invasive
lobular carcinoma, classic type.
Fig. 83 j, k: Low-power, large-section histology image (j) of this estrogen-receptor-positive (k) invasive lobular carcinoma.
Fig. 83g
Fig. 83h
Fig. 83i
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 83j
Fig. 83k
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84
An 81-year-old asymptomatic woman. First
mammography examination.
Physical examination
A “thickening” could be felt in the upper
outer quadrant of the right breast. Neither
skin changes nor nipple discharge were observed.
Mammography
Fig. 84 a, b: Detail of the right MLO (a) and
CC (b) projections. There is an asymmetric
density with slight architectural distortion
in the upper outer quadrant (rectangles).
Fig. 84a
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 84b
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Stellate/Spiculated Lesions and Architectural Distortion
Fig. 84 c, d: Microfocus magnification views
of the asymmetric density on the LM (c) and
CC (d) projections. Innumerable powdery
and crushed stone-like calcifications are
seen within the density.
Fig. 84 e–g: Specimen radiographs of largebore needle biopsy containing calcifications.
Histology showed grade 1 and 2 carcinoma
in situ.
Fig. 84 h–j: Operative specimen radiograph
with the architectural distortion and microcalcifications (h), correlated with the corresponding large thick-section (subgross, 3 D)
histology slice (i) and large thin-section histology (j).
Fig. 84c
Fig. 84d
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 84e
159
Fig. 84f
Fig. 84g
Fig. 84h
Fig. 84i–t e
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Stellate/Spiculated Lesions and Architectural Distortion
Fig. 84i
Fig. 84j
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
161
Fig. 84 k–o: Specimen radiograph with the
architectural distortion, consisting of dilated, tortuous ducts (k). The corresponding
large thick-section (subgross, 3 D) histology
slices (l, m, n) show the cancer-filled ductlike structures. Specimen radiograph (o)
shows a cluster of discernible calcifications.
Fig. 84k
Fig. 84l
Fig. 84m
Fig. 84n–t e
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V
Fig. 84n
Fig. 84o
Stellate/Spiculated Lesions and Architectural Distortion
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163
Fig. 84 p: Low-power microphotograph of
tightly packed cancer-filled duct-like structures characteristic of neoductgenesis.
Fig. 84 q: Details of a specimen radiograph
slice containing two clusters of discernible
microcalcifications.
Fig. 84p
Fig. 84q
Fig. 84r–t e
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Stellate/Spiculated Lesions and Architectural Distortion
Fig. 84 r: The corresponding histology slide
shows that some of the microcalcifications
are localized within the acini of an extremely distended TDLU.
Figs. 84 s, t: Histologic slices (H&E staining)—the cancer cells are associated with
amorphous (s) and psammoma body-like
(t) calcifications, corresponding to the microcalcifications seen on the mammograms.
Final Histology
Grade 2 solid and cribriform carcinoma in
situ over an area measuring 62 × 45 mm. No
sign of invasion was demonstrable.
Fig. 84r
Fig. 84s
Fig. 84t
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
85
Two consecutive mammography screening
examinations of this asymptomatic woman
are shown. The first mammogram at age 64
years was interpreted as normal, although
retrospective comparison reveals a nonspecific asymmetric density in the upper
outer quadrant. At the age of 66 years, still
asymptomatic, she was called back for further workup of the developing density in
the upper outer quadrant of the right breast.
Fig. 85a
Fig. 85 a, b: First examination, right breast,
details of the MLO (a) and CC (b) projections.
Fig. 85 c, d: 16 months later, right breast,
details of the MLO (c) and CC (d) projections.
A nonspecific asymmetric density with architectural distortion is seen in the upper
outer quadrant.
Analysis
The most frequent cause of an asymmetric
density on the mammogram is remnant of
normal parenchyma. These are called “specific asymmetric densities”, because two or
more of the four basic building blocks can be
165
identified. When the building blocks cannot
be demonstrated, the density is considered
to be a “nonspecific asymmetric density”.
The benign diagnostic option is a radial
scar. The malignant diagnostic options are
invasive lobular carcinoma or “neoductgenesis.” Since the mammographic features of a
radial scar are not present (see the description at the beginning of this chapter), only
the two malignant options remain.
Fig. 85 e: Low-power histology image of the
large-section specimen. The asymmetric
density seen on the mammogram consists
of numerous duct-like structures that are
distended by malignant cells.
Fig. 85b
Fig. 85c–g e
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Fig. 85c
Fig. 85e
Stellate/Spiculated Lesions and Architectural Distortion
Fig. 85d
Practice in Analyzing Stellate/Spiculated Lesions and Architectural Distortion on the Mammogram
Fig. 85 f, g: Histologic images with increasing magnification.
The cancer-filled, duct-like structures are
tightly packed and are surrounded by desmoplastic reaction, a typical picture of neoductgenesis.
Conclusion
Asymmetric densities with or without architectural distortion detected on the mammogram require a thorough workup.11
Fig. 85f
Fig. 85g
167
VI Calcifications on the Mammogram
Grade 3 ductal carcinoma in situ with casting-type calcifications.
Micropapillary carcinoma in situ with skipping stone-like calcifications.
Cystically dilated acini with psammoma body-like calcifications.
170
VI Calcifications on the Mammogram
When analyzing calcifications on the mammogram, the goal is to determine the pathological process that has produced them. The
analysis starts with determining the precise
site of origin of the calcifications. If the calcifications arise within structures that do
not contain breast epithelium (stroma,
skin, blood vessels, scar tissue), then they
are not malignant type, and are classified as
miscellaneous-type calcifications. They are
usually easily recognized, and their differential diagnosis presents few problems. Calcifications surrounding the ducts and
within the arterial walls, sebaceous glands,
oil cysts, etc. all belong to this group.
The remaining calcifications are formed
within the glandular tissue, that is, within
anatomic cavities lined by epithelial cells
(terminal ductal lobular units/TDLUs or
ducts). Analyzing the distribution of the calcifications on the mammogram will help to
determine whether they are located within
the TDLU(s) or within the ducts.
Linear, fragmented, branching calcifications are located within dilated ducts. The
dilatation may be caused by fluid accumulation (plasma cell mastitis/secretory disease-type calcifications) or by proliferation
of malignant cells (fragmented or dotted
casting-type calcifications). Differential diagnosis of calcifications formed within the
ducts is relatively easy.
Individual or multiple clusters indicate
that the pathological process takes place
within the TDLUs, which can be distended
by the accumulation of fluid (fibrocystic
change) or by malignant cells accompanied
by either necrosis (typical of grade 2 in situ
carcinoma) or by mucin (typically a product
of grade 1 in situ carcinoma cells). Differential diagnosis of calcifications formed
within the TDLUs may be difficult when
analyzing the mammograms alone. Largerbore needle biopsy under stereotactic guidance is often essential for differential diagnosis.
Once the location of the calcifications has
been determined, analysis of the form, size,
and density of the individual calcifications
will help in distinguishing benign from malignant-type calcifications through a closer
understanding of the underlying processes
producing them. Microfocus magnification
mammography is often essential for this
analysis, since it provides higher-resolution
images.
Malignant-Type Calcifications within Ducts
and/or in Terminal Ductal Lobular Units
Microcalcifications are often formed as a byproduct of the epithelial cell proliferation/
carcinoma in situ within the TDLUs and/or
the ducts. The mammographic appearance
of the malignant-type calcifications will be
largely dependent upon the malignancy
grade of the surrounding cell proliferation
and the location of the calcifications (within
the TDLUs or ducts). Their distribution will
reflect their site of origin—either ducts (linear, scattered within a lobe) or TDLUs (single or multiple clusters). The heterogeneity
of in situ carcinoma explains why the malignant-type microcalcifications will be extremely variable in form, size, and density.
These are described here in detail.
Form
Despite their wide variation in appearance,
the malignant-type calcifications can be
classified into four basic forms. The corresponding terminology of the American College of Radiology Breast Imaging-Reporting
and Data System (BI-RADS) is given in parentheses.1
• Casting-type calcifications. When highgrade carcinoma in situ extensively fills in
the ducts and their branches, the central
portion of the lumen will contain necrotic
cellular debris. Within this necrosis,
amorphous calcifications are formed.2
— When the growth pattern of the malignant cells is predominantly solid, the
mammographic presentation will be
fragmented casting type (BI-RADS:
fine linear branching calcifications)
(Fig. XXV). These are seen on the
mammogram as linear, often branching calcifications with irregular contours. It is the ductal lumen that determines the maximum width of the
individual castings. Microfocus magnification views reveal that the calcification fragments differ in density,
length, and outline (Cases 90, 92, 96,
99–101, 103–105, 108, 109). The differential diagnosis of the fragmented
casting-type calcifications includes
only the secretory-type/plasma cell
mastitis-type calcifications. Whereas
the casting-type calcifications are unilateral and restricted to a single breast
lobe, the benign secretory disease-type
calcifications are bilateral and widespread.
— In cases where the growth pattern of
the malignant cells is predominantly
micropapillary, dotted casting-type
calcifications will be seen on the
mammogram. The tips of the evergrowing micropapillary extensions
eventually break off and fill up the
ductal lumen, where they gradually
calcify. The appearance of these calcifications is pathognomonic (Case 102).
• Skipping stone-like calcifications in the
ducts. When the growth pattern of the
malignant cells is micropapillary/cribriform and the cancer cells produce proteinaceous fluid, filling the spherical, intratumoral cavities of the cribriform cancer and distending the ducts containing
the micropapillary growths, large, spheroid calcifications may be formed within
the fluid. These flat, smooth-contoured
calcifications are reminiscent of skipping
stones. They fill out a single breast lobe
with a fairly uniform intralobar distribution. In this subtype of breast cancer,
analysis of the form of the calcifications is
of little value and will not lead to the
correct diagnosis. Unilateral distribution
of skipping stone-like calcifications
within a single lobe should raise the suspicion of this special subtype of breast
cancer (Case 106).
• Crushed stone-like/pleomorphic calcifications (BI-RADS: pleomorphic, heterogeneous).1,3 The individually discernible
particles resemble crushed stones or
granulated sugar crystals. They are irregular in form, size, and density, and grouped
very close together in single (Fig. XXVI) or
multiple clusters. The malignant cells and
the associated necrosis distend the acini
within the TDLU. The amorphous calcifications are formed within this necrosis.
Their location within the distended TDLU
accounts for their closeness to each other
and for their clustered distribution. Since
the malignant cells originate within the
lobule(s), the term “ductal carcinoma in
situ (DCIS)” is a misnomer. These calcifications are typically seen in grade 2 in situ
carcinoma, the most frequent form of in
situ cancer (Cases 86, 87, 88, 94). Three
types of benign, hyperplastic breast
changes may present on the mammogram
Malignant-Type Calcifications within Ducts and/or in Terminal Ductal Lobular Units
as clustered, discernible, irregular calcifications—fibrocystic change, fibroadenoma, and papilloma. These are the differential diagnostic counterparts for
grade 2 in situ carcinoma localized within
the TDLUs. Stereotactic percutaneous
needle biopsy can provide the correct diagnosis.
• Powdery/cotton ball-like calcifications
(BI-RADS: amorphous, indistinct).1,3
Psammoma-body-like calcifications may
be formed within the mucin secreted by
grade 1 in situ carcinoma cells, which
proliferate within the acini of the TDLUs.
The calcium particles are far too small to
be individually perceptible, but the summation of many of them can be seen on
the mammogram as multiple clusters of
powdery/cotton ball-like calcifications
(Cases 95, 97, 98, 107, 120). The BI-RADS
terminology for this kind of calcifications
is “amorphous,” an unfortunate choice,
since the term “amorphous” has long
been used by pathologists to describe the
calcifications associated with apoptosis
within the TDLUs (grade 2 in situ carcinoma) or within the ducts (grade 3 in situ
carcinoma). Additionally, these calcifications are not amorphous, since they are
crystalline spheres. Use of the same term
(amorphous) to describe vastly different
calcification types that represent disparate disease processes has the potential of
confusing communication between radiologists and pathologists. Multiple clusters of powdery/cotton ball-like calcifications on the mammogram may be seen
with either grade 1 in situ carcinoma or
sclerosing adenosis. Since both the benign, hyperplastic breast change (sclerosing adenosis) and the malignant process (grade 1 in situ carcinoma) develop
within the TDLUs and both are associated
with similarly appearing psammoma
body-like calcifications, radiologic differentiation of these two entities is not
possible. Multiple cluster powdery calcifications seen on the mammogram will
have an approximately 50 % probability of
representing grade 1 in situ cancer (Cases
97, 98, 107).
Size
These calcifications arise within the lumens
of the TDLU(s) or duct(s), and are thus limited in size to these dimensions—hence, the
term microcalcifications.
Density
Density analysis should include a comparison of the densities of the individual particles with each other (interparticulate den-
171
sity analysis). The crushed stone-like/pleomorphic and casting-type calcifications
both show great variations in density
among adjacent particles.
Number
Although the actual number of calcifications
has been considered by some to have diagnostic significance, the distribution, form,
size, and density of the calcifications are of
far greater importance. Magnification mammography in particular has demonstrated
that the number of calcifications visible
can be highly dependent upon the mammography technique. The number of
crushed stone-like/pleomorphic calcifications may vary considerably from cluster
to cluster, the number of calcification particles in the dotted casting type are innumerable, and the powdery/cotton ball-like
calcifications are not countable. It is important to note that the casting-type calcifications are so characteristic of grade 3 in situ
carcinoma, that the diagnosis can be made
on the basis of one or two such calcifications
alone (Cases 101, 105).
172
VI Calcifications on the Mammogram
Calcifications Localized within Ducts
Calcifications Localized within Terminal Ductal Lobular
Units
Fig. XXIII Subgross (3 D) histology image of a normal pleated duct with
adjoining TDLUs.
Fig. XXVI Crushed stone-like calcifications within a TDLU. The individual
particles are irregular in size, shape, and density, and are grouped in a
cluster.
Fig. XXIV Large-section histology image of a duct distended by grade 3
in situ carcinoma.
Fig. XXVII Fibrocystic change with psammoma body-like calcifications.
Fig. XXV Diagram of an extremely distended duct with solid-cell proliferation, central necrosis, and amorphous, casting-type calcifications.
Practice in Calcification Analysis
173
Practice in Calcification
Analysis
(Cases 86–109)
86
A 48-year-old asymptomatic woman. Two
consecutive screening examinations.
Mammography
First screening examination.
Fig. 86 a: Right breast, detailed view of the
mediolateral oblique (MLO) projection. Normal mammogram.
Second screening examination, 24 months
later. No palpable tumor.
Fig. 86 b: Right breast, detailed view of the
MLO projection. A cluster of microcalcifications is now seen in the upper half of the
breast (arrow). No associated tumor mass is
demonstrable.
Fig. 86 c, d: Right breast, microfocus magnification views, MLO and craniocaudal (CC)
projections.
Fig. 86a
Analysis of the Calcifications
The de novo, tiny, crushed stone-like/pleomorphic calcifications are irregular in form,
size, and density and occur in a compact
cluster. This is a typical mammographic image of malignant-type, crushed stone-like/
pleomorphic calcifications within a single
TDLU.
Fig. 86 e, f: Operative specimen radiographs,
magnification view.
Histology
In situ carcinoma with necrosis within a
TDLU. Histology also reveals invasion.
Follow-up
The woman was still alive 19 years later.
Fig. 86b
Fig. 86c–f e
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VI Calcifications on the Mammogram
Fig. 86c
Fig. 86d
Fig. 86e
Fig. 86f
Practice in Calcification Analysis
175
87
Asymptomatic 50-year-old woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 87 a: Left breast, MLO projection. Two
clusters of microcalcifications are seen in
the upper half of the breast (arrow). In addition, a solitary, 4-mm eggshell-like calcification is seen in the central portion of the
breast, mammographically benign.
Fig. 87 b, c: Magnification view, MLO projection and specimen radiography.
Analysis of the Clustered Calcifications
Distribution: cluster; the calcifications are
seen very near to each other in a small
area of the breast
Form: crushed stone-like/pleomorphic,
some elongate; highly irregular
Density: variable
Fig. 87a
Conclusion
Mammographically malignant type, crushed
stone-like/pleomorphic microcalcifications.
Fig. 87b
Fig. 87c
Fig. 87d–f e
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VI Calcifications on the Mammogram
Histology
In situ carcinoma within TDLUs; solid-cell
proliferation, intraluminal necrosis and
amorphous calcifications within the distended acini.
Fig. 87 d: Low-power view of the grade 2
carcinoma in situ involving several TDLUs
(hematoxylin and eosin [H&E], 40 ×).
Fig. 87 e: The acini from one TDLU filled
with malignant cells, corresponding to one
cluster on the mammogram (H&E, 100 ×).
Fig. 87 f: Higher-power magnification of a
single acinus showing the cellular details
of a grade 2 carcinoma in situ (H&E, 200 ×).
Follow-up
The woman died 15 years later from myocardial infarction, with no evidence of
breast cancer at the time of death.
Fig. 87d
Fig. 87e
Fig. 87f
Practice in Calcification Analysis
177
88
This 68-year-old woman felt a thickening in
the lateral portion of her left breast.
Mammography
Fig. 88 a, b: Left breast, CC projection, detailed view of the contact mammogram
and microfocus magnification view. Innumerable calcifications of varying form,
size, and density. They are a mixture of the
casting-type (long, fragmented, some of
them branching) and the skipping stonelike (fairly large, high-density, some ovalshaped) calcifications, and are surrounded
by an ill-defined density.
Fig. 88a
Conclusion
Mammographically malignant-type calcifications with an associated ill-defined, nonspecific density.
Histology
Infiltrating ductal carcinoma, with an extensive associated in situ component.
Fig. 88 c: Low-power view of the micropapillary ductal carcinoma in situ component
(H&E, 40 ×).
Fig. 88 d, e: Higher magnification of the
grade 2 micropapillary carcinoma in situ.
The ducts are distended by the fluid produced by the cancer cells. Within this fluid,
skipping stone-like calcifications are seen
randomly, corresponding to the larger calcifications on the mammogram (H&E, 200 ×
and 300 ×).
Fig. 88 f: Cellular details of this grade 2 micropapillary ductal carcinoma in situ with a
portion of the fluid-filled lumen (H&E,
400 ×).
Fig. 88b
Follow-up
The woman was still alive 19 years later at
the age of 87 years, with no evidence of
breast cancer.
Fig. 88c
Fig. 88d–f e
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VI Calcifications on the Mammogram
Fig. 88d
Fig. 88e
Fig. 88f
Practice in Calcification Analysis
89
Mammography
Fig. 89 a: Right breast, detailed view of the
CC projection.
Fig. 89 b: Microfocus magnification view.
There are numerous fragmented castingtype calcifications, indicating the presence
of malignancy in a large volume of the
breast.
Histology
Grade 3 in situ carcinoma with solid-cell
proliferation, central necrosis and amorphous calcifications. No histologic signs of
invasion.
Comment
The disorganized, haphazard arrangement
of the calcifications that outline the ductlike structures indicates the presence of
neoductgenesis.2
Fig. 89a
Fig. 89b
179
180
VI Calcifications on the Mammogram
90
This 27-year old woman felt a lump in her
left breast.
Mammography
Fig. 90 a: Detailed view of the MLO projection, left breast.
Fig. 90 b: Enlarged view of the portion of the
left breast containing the palpable tumor.
There are numerous fragmented castingtype, branching calcifications associated
with architectural distortion. The findings
are characteristic of a malignant breast tumor.
Histology
Infiltrating carcinoma with lymph node
metastases.
Fig. 90 c: Low-power view of the invasive
ductal carcinoma including an in situ component (H&E, 40 ×).
Fig. 90 d: Poorly differentiated invasive ductal carcinoma (H&E, 200 ×).
Fig. 90 e: Axillary lymph node containing
metastases (H&E, 200 ×).
Fig. 90a
Follow-up
The patient died 2 years later of metastatic
breast carcinoma, aged 29 years.
Comment
The patient had a classic, poorly differentiated invasive ductal carcinoma in addition
to invasive, poorly differentiated duct-forming invasive cancer, revealed by the castingtype calcifications. This large tumor burden
was fatal.
Fig. 90b
Practice in Calcification Analysis
Fig. 90c
Fig. 90d
Fig. 90e
181
182
VI Calcifications on the Mammogram
91
Routine screening examination of this 62year-old asymptomatic woman.
Mammography
Fig. 91 a, b: Right breast, detailed view of
the CC projection (a) and microfocus magnification view (b). There are innumerable
branching, fragmented casting-type calcifications of varying length and density. An illdefined density surrounds the calcifications. This may correspond to either infiltration or desmoplastic reaction.
Fig. 91a
Conclusion
The presence of fragmented casting-type
calcifications associated with a large ill-defined density is pathognomonic for an aggressive, highly malignant cancer.
Histology
Invasive ductal carcinoma associated with
high-grade ductal carcinoma in situ with
central necrosis.
Fig. 91 c: Low-power histologic image demonstrates a large number of tightly packed,
cancer-filled duct-like structures with central necrosis and amorphous calcifications
corresponding to the casting-type calcifications on the mammogram (H&E, 40 ×).
Comment
Both the mammographic and histologic image are characteristic for neoductgenesis.2
Fig. 91b
Follow-up
The woman died 13 years later from myocardial infarction, aged 74 years. There was
no evidence of breast cancer.
Fig. 91c
Practice in Calcification Analysis
92
Mammography
Fig. 92 a–d: Microfocus magnification mammography of four cases of fragmented, casting-type, mammographically malignanttype calcifications. The calcifications differ
in density, width, and length, and are irregular in outline. They are tightly packed and
point in all directions, forming a disorganized pattern characteristic of neoductgenesis.
Fig. 92a
Fig. 92b
Fig. 92c
Fig. 92d
183
184
VI Calcifications on the Mammogram
93
An asymptomatic woman aged 40 years.
First screening examination.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 93 a, b: Left breast, detailed views of the
MLO and CC projections. There is a small
group of calcifications in the lower outer
quadrant, without an associated tumor
mass.
Fig. 93 c: Microfocus magnification view of
the area with calcifications in the MLO projection.
Analysis
This is an additional example of fragmented
and dotted casting-type calcifications.
These are formed within segments of a
duct and its branches. The ductal lumen
contains the grade 3 in situ carcinoma cells,
central necrosis, and amorphous calcification fragments of varying length, density,
and outline.
Fig. 93 d: Operative specimen radiograph,
magnification.
Histology
Invasive and in situ ductal carcinoma. No
lymph node metastases.
Fig. 93 e: Overview of the 3-mm invasive
component associated with an in situ focus
(H&E, 40 ×).
Fig. 93 f: Higher-power histologic image of
the invasive tumor (H&E, 220 ×).
Fig. 93 g, h: Cellular details of the extensive
grade 3 ductal carcinoma in situ (H&E,
600 ×).
Fig. 93 i: Overview of the retromamillary
area with extension of the high-grade ductal carcinoma in situ (H&E, 12.5 ×).
Fig. 93 j: High-power view of the retromamillary ductal carcinoma in situ (H&E,
600 ×).
Follow-up
The woman was still alive 20 years later at
the age of 60 years.
Fig. 93a
Fig. 93b
Practice in Calcification Analysis
Fig. 93c
185
Fig. 93d
Fig. 93e
Fig. 93f–j e
186
VI Calcifications on the Mammogram
Fig. 93f
Fig. 93g
Fig. 93h
Practice in Calcification Analysis
Fig. 93i
Fig. 93j
187
188
VI Calcifications on the Mammogram
94
An asymptomatic 75-year-old woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 94 a, b: Left breast, detailed views of the
MLO and CC projections. In the upper outer
quadrant there are two clusters of calcifications surrounded by an ill-defined density.
Fig. 94 c, d: Microfocus magnification views,
MLO and CC projections.
Analysis of the Calcifications
Distribution: cluster
Form: crushed stone-like/pleomorphic, variable in shape
Density: highly variable, some fade into the
background
Fig. 94a
Conclusion
Mammographically malignant-type calcifications within an ill-defined density. The
cluster distribution suggests that the malignant process is confined to the TDLU.
Histology
In situ carcinoma with minimal invasion.
Fig. 94 e: Low-power magnification of this
grade 2 carcinoma in situ within a TDLU.
The amorphous calcifications correspond
to the microcalcifications seen on the mammogram (H&E, 20 ×).
Fig. 94 f: Higher-magnification histology
image showing a single acinus with solid
proliferation of malignant cells (H&E, 200 ×).
Follow-up
The woman died 12 years later from pneumonia at the age of 87 years, with no evidence of breast cancer at the time of death.
Fig. 94b
Practice in Calcification Analysis
Fig. 94d
Fig. 94c
Fig. 94e
Fig. 94f
189
190
VI Calcifications on the Mammogram
95
This 45-year-old asymptomatic woman was
called back from mammography screening
for assessment of the multiple cluster calcifications detected in the upper outer quadrant of her left breast.
Mammography and Ultrasound
Fig. 95 a, b: Left breast, detail of the MLO
projection (a) and microfocus magnification
(b) of the region containing the multiple
clusters of powdery calcifications.
Fig. 95 c, d: Left breast, detail of the CC projection (c) and microfocus magnification
view (d) of the region in the rectangle. The
numerous powdery/cotton ball-like calcifications are hidden in extremely dense fibrosis. No tumor mass is demonstrable.
Fig. 95 e: Left breast, additional detail of the
CC projection, microfocus magnification
view.
Fig. 95 f: Hand-held ultrasound helps to detect mammographically occult small, simple
cysts.
Fig. 95 g: Specimen radiograph following
preoperative localization using the bracketing technique.
Fig. 95a
Fig. 95b
Practice in Calcification Analysis
191
Fig. 95c
Fig. 95d
Fig. 95e–q e
192
VI Calcifications on the Mammogram
Fig. 95e
Fig. 95f
Fig. 95g
Practice in Calcification Analysis
193
Fig. 95 h–k: Specimen slice radiographs.
There are innumerable clusters of powdery/cotton ball-like calcifications throughout each slice. In addition, there are a few
clusters containing discernible, round, highdensity calcifications. No tumor mass is demonstrable.
Fig. 95h
Fig. 95i
Fig. 95j–q e
194
VI Calcifications on the Mammogram
Fig. 95j
Fig. 95k
Practice in Calcification Analysis
195
Histology
Sclerosing adenosis without malignancy.
Fig. 95 l: Large-section histology, low-power
image. The abnormal tissue (between the
dashed lines) occupies an area of 5 cm.
Fig. 95 l–q: Low and intermediate power
histologic images (H&E). The psammomabody-like calcifications are localized within
lobules, associated with sclerosing adenosis.
There is no epithelial cell atypia, and no
malignancy was found.
Fig. 95l
Fig. 95m
Fig. 95n–q e
196
VI Calcifications on the Mammogram
Fig. 95n
Fig. 95o
Fig. 95p
Practice in Calcification Analysis
Fig. 95q
197
198
VI Calcifications on the Mammogram
96
An asymptomatic woman, aged 61 years.
First screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 96 a: Right breast, MLO projection. A
cluster of calcifications is seen in the axillary portion of the breast (arrow), with no
associated tumor mass.
Fig. 96 b: Right breast, microfocus magnification view, MLO projection.
Analysis
Distribution: cluster
Form: a mixture of crushed stone-like/pleomorphic and fragmented casting-type calcifications
Density: varies between high density and
barely visible
Size: microcalcifications of variable size. A
few elongated, casting-type calcifications
are evident
Fig. 96a
Conclusion
Mammographically malignant-type calcifications. The casting-type calcifications are
pathognomonic for a high-grade in situ carcinoma.
Histology
Carcinoma in situ without a demonstrable
invasive component.
Fig. 96 c: Grade 3 carcinoma in situ with
central necrosis and amorphous calcifications, with surrounding desmoplastic reaction and lymphocytic infiltration (H&E,
20 ×).
Fig. 96 d: Higher-power magnification of a
single, cancerous duct (H&E, 300 ×).
Follow-up
The woman was still alive 20 years later,
with no evidence of breast cancer.
Fig. 96b
Practice in Calcification Analysis
Fig. 96c
Fig. 96d
199
200
VI Calcifications on the Mammogram
97
This 48-year-old asymptomatic woman was
called back for further assessment of a small
group of powdery calcifications detected in
the lower portion of the right breast.
Mammography
Fig. 97 a, b: Right breast, detail of the MLO
projection (a) and microfocus magnification
of the area with the powdery calcifications
(b).
Fig. 97 c: An additional microfocus magnification image of the region with the powdery calcifications.
Fig. 97 d: Specimen radiograph of the largebore percutaneous needle biopsy. A large
number of calcifications are included in
the biopsy specimen.
Fig. 97 e–g: Histology of the percutaneous
large-bore needle biopsy: one dilated TDLU
contains low-grade cancer in situ and
psammoma body-like calcifications corresponding to the microcalcifications seen
on the mammogram.
Fig. 97 h, i: Histology of the surgical specimen: one TDLU is distended by low-grade
carcinoma in situ without associated calcifications (occult on mammography). Multifocal grade 1 carcinoma in situ.
Fig. 97a
Fig. 97b
Practice in Calcification Analysis
201
Analysis of the Calcifications
Distribution: cluster
Form: powdery, cotton ball-like
Density: very faint
Conclusion
Microscopic diagnosis in each powdery calcification case is necessary because sclerosing adenosis and grade 1 in situ carcinoma
cannot be differentiated solely by radiologic
imaging, since the calcifications associated
with both of these diseases are identical.
Fig. 97c
Fig. 97d
Fig. 97e–i e
202
VI Calcifications on the Mammogram
Fig. 97e
Fig. 97f
Fig. 97g
Fig. 97h
Fig. 97i
Practice in Calcification Analysis
98
This 78-year-old woman was operated in
her left breast at the age of 70 years, for a
9 × 6 mm invasive lobular cancer associated
with grade 1 in situ carcinoma and lobular
carcinoma in situ over an area measuring
50 × 60 mm. Eight years later, her right
breast mammograms showed a de novo,
oval, lobulated density associated with
powdery calcifications.
Fig. 98a
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 98 a, b: Right LMO (a) and CC (b) projections. The de novo density associated
with powdery calcifications is seen encircled.
Fig. 98 c, d: Microfocus magnification views
on the LM (lateromedial) (c) and (d) CC projections. An ill-defined, unusually lobulated
tumor mass contains numerous clusters of
powdery calcifications.
Fig. 98b
203
Conclusion
An ill-defined, lobulated tumor associated
with powdery calcifications is, with high
probability, a malignant breast tumor associated with low-grade in situ carcinoma.
Fig. 98 e–g: Radiographs of the vacuum-assisted biopsy specimen.
Fig. 98 h: Histologic examination of the percutaneous biopsy specimen reveals invasive
ductal carcinoma and grade 1 in situ cancer.
Fig. 98 i, j: Operative specimen radiographs.
204
VI Calcifications on the Mammogram
Fig. 98c
Fig. 98d
Practice in Calcification Analysis
Fig. 98e
Fig. 98f
Fig. 98g
Fig. 98h
Fig. 98i
Fig. 98j
205
Fig. 98k–s e
206
VI Calcifications on the Mammogram
Fig. 98 k: Large-section histology of the surgically removed tissue.
Histology
9 × 6 mm moderately differentiated invasive
ductal carcinoma associated with grade 1 in
situ cancer (Fig. 98 h) and lobular cancer in
situ on an area measuring 60 × 50 mm. None
of the three surgically removed sentinel nodes showed signs of metastases.
Fig. 98 l, m: Low- and intermediate-power
histology images of the moderately differentiated invasive carcinoma component
(within the area marked with a rectangle
on Fig. 98 k).
Fig. 98 n, o: Low- and high-power histology
images of the associated in situ carcinoma
(within the area marked with an oval on
Fig. 98 k).
Fig. 98 p, q: Low- and intermediate-power
images of in situ carcinoma foci 45 mm
from the invasive carcinoma.
Fig. 98 r, s: Psammoma body-like calcifications within the in situ cancer localized
close to the invasive cancer. These correspond to the powdery calcifications on the
mammogram.
Fig. 98l
Fig. 98k
Fig. 98m
Practice in Calcification Analysis
Fig. 98n
Fig. 98o
Fig. 98p
Fig. 98q
Fig. 98r
Fig. 98s
207
208
VI Calcifications on the Mammogram
99
A 74-year-old woman, not aware of any
breast abnormality. First screening examination.
Mammography
Fig. 99 a: Left breast, detailed view of the
MLO projection. In the upper outer quadrant there is a 5 × 5 cm area containing numerous calcifications associated with a nonspecific, ill-defined density.
Fig. 99 b, c: Microfocus magnification views,
MLO and CC projections. Most of the calcifications are of the fragmented casting type,
mammographically malignant.
Analysis
This case gives an excellent opportunity to
demonstrate the fragmented casting-type
calcifications. Their shape is determined
by the uneven production of calcification
within the irregular central necrosis. The
lumen contains consecutive fragments; the
contour of these calcifications is irregular,
and their density, although high, varies
from particle to particle. A calcification
may be branching when it extends into adjacent branches of a duct.
Histology
Poorly differentiated invasive ductal carcinoma associated with a grade 3 ductal carcinoma in situ. No lymph node metastases
were detected at the time of surgery.
Fig. 99a
Fig. 99b
Fig. 99c
Note
The infiltration probably accounts for some
of the density surrounding the calcifications.
Follow-up
The patient died 2 years 5 months later of
metastatic breast carcinoma, aged 76 years.
Comment
This is a typical example of neoductgenesis
where the newly formed duct-like structures are filled with high-grade carcinoma
cells, necrosis, and casting-type calcifications. These consist of poorly differentiated
“duct-forming invasive carcinoma” (rather
than in situ cancer), and together with the
associated conventional invasive carcinoma, the patient was subjected to a large,
aggressive tumor burden.2
Practice in Calcification Analysis
209
100
A 73-year-old asymptomatic woman. First
screening examination.
Mammography
Fig. 100 a: Left breast, CC projection. A group
of calcifications is seen in the central portion of the breast (arrows).
Fig. 100 b: Microfocus magnification view of
the region with microcalcifications, CC projection.
Analysis
Typical intraductal, casting-type calcifications. They are irregular in shape, size, and
density, and follow the course of a duct and
its branches.
Conclusion
Mammographically malignant-type calcifications.
Fig. 100a
Histology
High-grade carcinoma in situ with no sign
of invasion.
Fig. 100 c: Grade 3 carcinoma in situ with
central necrosis and amorphous calcification. The closely packed duct-like structures, their irregular shape, and the presence of extensive desmoplastic reaction and
lymphocytic infiltration suggest that these
are newly formed ducts, the result of neoductgenesis (H&E, 40 ×).
Fig. 100 d: High-power magnification of one
of the duct-like structures (H&E, 100 ×).
Follow-up
The woman died 8 months later from myocardial infarction, aged 74 years. At the
time of death there was no evidence of
breast cancer.
Fig. 100b
Fig. 100c, d e
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VI Calcifications on the Mammogram
Fig. 100c
Fig. 100d
Practice in Calcification Analysis
211
101
Routine screening examination of this 64year-old asymptomatic woman.
Mammography
Fig. 101 a: Right breast, CC projection. Casting-type calcifications extend from the retroareolar region (arrows).
Fig. 101 b: Coned-down compression and
microfocus magnification view, CC projection. The typical casting-type calcifications,
one of them branching, are a reliable mammographic sign of carcinoma.
Histology
High-grade carcinoma in situ.
Fig. 101 c: Low-power view of an area with
cancer-filled duct-like structures with minimal calcification (H&E 20 ×).
Fig. 101 d: Cellular details demonstrating
marked atypia and central necrosis, without
calcifications (H&E, 200 ×).
Fig. 101 e: Cross-section of a duct with extensive central necrosis and calcification
filling nearly the entire duct lumen. Only a
few viable cancer cells are visible (H&E,
200 ×).
Comment
The rapidly growing malignant cells in
high-grade in situ carcinoma developing in
the ducts undergo necrosis and calcification. As the process of calcification progresses, individual calcification fragments
acquire a higher density and a smoother
contour, and may eventually begin to resemble the petrified fluid of secretory disease/plasma-cell mastitis-type calcifications. These later-stage calcifications will
have few associated viable cancer cells.
However, surrounding these benign-appearing fragments, there will always be
fainter casting-type calcifications indicating
the true nature of the disease. Microfocus
magnification is important for the diagnosis. Preoperative percutaneous stereotactic
biopsy should target the fainter calcifications, which are associated with the viable
cancer cells.
Fig. 101a
Fig. 101b
Follow-up
The woman was still alive 18 years later,
aged 82 years.
Fig. 101c–e e
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VI Calcifications on the Mammogram
Fig. 101c
Fig. 101d
Fig. 101e
Practice in Calcification Analysis
102
A 28-year-old woman, who felt a lump in
the upper outer quadrant of the right breast.
Physical Examination
Instead of a palpable, distinct tumor mass,
the entire upper outer quadrant of the right
breast was hard and there was a large palpable lymph node in the right axilla.
Mammography
Fig. 102 a–c: Right breast, detailed views of
the MLO projection with contact (a) and
microfocus magnification mammography
(b, c). The entire upper half of the breast is
filled with innumerable calcifications. Most
striking, one duct and its main branches are
completely filled with calcifications all the
way to the nipple. No associated tumor
mass is demonstrable.
Fig. 102a
Fig. 102 d: Operative specimen magnification radiograph.
Analysis
There is an unusual picture of innumerable
casting-type calcifications spread over a
large area of the breast, filling in one large
lobe. The calcifications are predominantly
of the dotted casting type, although in the
peripheral regions, in the axillary tail there
are fragmented casting-type calcifications
as well.
Conclusion
The fragmented and dotted casting-type
calcifications are pathognomonic for a
most aggressive subtype of breast cancer.
Histology
High-grade in situ carcinoma distributed
over an area of at least 15 cm in diameter,
associated with small foci of invasive,
poorly differentiated ductal carcinoma. Axillary lymph node metastases were present.
Fig. 102b
213
Fig. 102 e: Overview of both invasive and in
situ ductal carcinoma (H&E, 12.5 ×).
Fig. 102 f: Detailed view of the micropapillary and cribriform in situ component with
cellular atypia (H&E, 200 ×).
Fig. 102 g: Further details of the grade 3
micropapillary carcinoma in situ showing
central necrosis (H&E, 200 ×).
Follow-up
The patient died 3 years 7 months later of
metastatic breast carcinoma, aged 31 years.
Comment
This is another example of neoductgenesis.
The pre-existing main duct contains the
typical dotted casting-type calcifications.
Note that the newly formed, disorganized
duct-like structures are more peripheral,
consisting of poorly differentiated “ductforming invasive carcinoma,” rather than
in situ cancer. This young patient had an
extremely large, aggressive, and fatal tumor
burden.
Fig. 102c–g e
214
VI Calcifications on the Mammogram
Fig. 102c
Fig. 102d
Fig. 102e
Practice in Calcification Analysis
Fig. 102f
Fig. 102g
215
216
VI Calcifications on the Mammogram
103
A 62-year-old asymptomatic woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 103 a–c: Left breast, CC projection and
detailed views in the CC and ML projections.
An oval tumor with associated calcifications
is seen 5 cm from the nipple.
Analysis of the Tumor
Form: oval, lobulated
Contour: partially sharply outlined (arrows).
Parenchymal structures obscure some of
the tumor border
Density: low-density radiopaque
Size: 15 × 10 mm
Fig. 103a
Analysis of the Calcifications
Distribution: within the tumor
Form: irregular, some of them casting type
Density: highly variable
Conclusion
Mammographically malignant-type calcifications within an oval tumor mass.
Histology
High-grade carcinoma in situ within a fibroadenoma.
Fig. 103 d: Overview of the fibroadenoma
(H&E, 12.5 ×).
Fig. 103 e, f: H&E, 200 × (e) and 400 × (f).
Higher magnification reveals an in situ carcinoma with pleomorphic nuclei and amorphous calcifications within the fibroadenoma.
Fig. 103b
Follow-up
The woman died 13 years later from acute
myocardial infarction, aged 75 years. There
was no evidence of breast cancer at the time
of death.
Practice in Calcification Analysis
Fig. 103d
Fig. 103c
Fig. 103e
Fig. 103f
217
218
VI Calcifications on the Mammogram
104
A 46-year-old asymptomatic woman. First
screening examination.
Mammography
Fig. 104 a: Left breast, microfocus magnification view in the MLO projection. Numerous calcifications are seen, with no associated tumor.
Analysis
Typical fragmented casting-type calcifications. These are mammographically characteristic of malignancy. A single, dense, benign-appearing calcification (arrow) is
superimposed.
Histology
High-grade carcinoma in situ with minimal
invasion, but no axillary lymph node metastases.
Fig. 104 b: A neoduct is seen in longitudinal
section. There are random side branches
filled with high-grade cancer cells, central
necrosis, extensive periductal desmoplastic
reaction, and lymphocytic infiltration (H&E,
100 ×).
Fig. 104 c: Cross-section of a duct-like structure with central necrosis and amorphous
microcalcifications (H&E, 300 ×).
Fig. 104 d: Carcinoma cells showing high
nuclear grade and high mitotic activity are
associated with central necrosis in this
newly formed duct-like structure (H&E,
300 ×).
Fig. 104 e: Foci of microinvasion in the vicinity of a cancerous duct-like structure (H&E,
200 ×).
Fig. 104a
Fig. 104b
Follow-up
The woman was still alive 18 years later at
the age of 64 years.
Fig. 104c
Practice in Calcification Analysis
Fig. 104d
Fig. 104e
219
220
VI Calcifications on the Mammogram
105
An 80-year-old woman, with a 2-month history of eczematous change of the nipple.
Physical Examination
Fig. 105 a: The appearance of the nipple resembles Paget’s disease. There is no palpable breast tumor.
Mammography
Fig. 105 b: Left breast, microfocus magnification view, MLO projection. A single casting-type calcification (solid arrow) and a
group of crushed stone-like/pleomorphic
calcifications (open arrow) are seen with
no associated tumor. An additional solitary,
benign-type, smooth-bordered calcification
typical of a calcified hematoma is in the
lower portion of the image.
Fig. 105a
Analysis
Both the crushed stone-like/pleomorphic
and casting-type calcifications indicate the
presence of a malignant breast lesion.
Conclusion
The presence of punch-biopsy-proven Paget’s disease mandates a search for a focus
of underlying carcinoma in the breast. In
most cases, the malignant-type calcifications indicate the site of malignancy.
Histology
High-grade carcinoma in situ with associated calcifications in the retroareolar region. Paget’s disease of the nipple.
Comment
Paget’s disease of the breast, first described
by James Paget in 18744, is a special form of
breast cancer associated with eczematous
changes of the nipple. The clinical picture
is dominated by the eczematous, malignant
nipple lesion, while the underlying breast
cancer is usually occult to palpation, but
can be demonstrated mammographically
in most cases.
Fig. 105b
Practice in Calcification Analysis
106
This 62-year-old woman was called back
from mammography screening for assessment of the de novo calcifications detected
on the mammogram in the lateral portion of
the right breast.
Fig. 106a
Physical Examination
Physical examination revealed no abnormalities.
Mammography
Fig. 106 a, b: Details of the MLO projection
(a) and microfocus magnification (b). There
are numerous dilated ducts in one lobe,
containing scattered calcifications.
221
Fig. 106 c, d: Detailed images of the right CC
projection (c) and microfocus magnification
(d), showing the dilated ducts and the scattered, skipping stone-like calcifications.
Fig. 106 e, f: Hand-held ultrasound images:
the distended, fluid-filled ducts are seen in
cross-section. No tumor mass is demonstrable.
Fig. 106b
Fig. 106c
Fig. 106d
Fig. 106e–x e
222
VI Calcifications on the Mammogram
Fig. 106 g–l: Breast magnetic resonance
imaging (MRI) images demonstrate contrast
enhancement throughout an entire lobe
(70 × 20 × 30 mm) in the lateral portion of
the right breast, corresponding to the region with the distended ducts and skipping
stone-like calcifications on the mammograms.
Fig. 106e
Conclusion
The skipping stone-like calcifications with a
lobar distribution raise the suspicion of a
fluid-producing in situ carcinoma of ductal
origin (micropapillary and/or cribriform cell
architecture). These are malignant-type calcifications requiring microscopic confirmation.
Fig. 106 m: Specimen radiograph of the percutaneous radiofrequency directed biopsy.
Fig. 106 n, o: Histologic examination (H&E
staining): micropapillary cancer in situ in
numerous duct-like structures.
Fig. 106f
Fig. 106g
Fig. 106i
Analysis of the Calcifications
Distribution: diffusely scattered within a
lobe, localized within distended ducts
Form: “skipping stone-like” calcifications
Density: variable
Fig. 106h
Fig. 106j
Fig. 106k
Fig. 106l
Practice in Calcification Analysis
Fig. 106m
223
Fig. 106n
Fig. 106o
Fig. 106p–x e
224
VI Calcifications on the Mammogram
Fig. 106 p: Operative specimen slice radiograph. There are duct-like structures arranged in a radiating fashion, mimicking a
stellate tumor.
Fig. 106 q: Large thick-section (3 D) histology of the specimen slice shown on
Fig. 106 p. The radiating structure demonstrated on Fig. 106 p corresponds to dilated,
tortuous cancer-filled duct-like structures.
Fig. 106 r: Detailed view of the specimen
slice containing the distended, tortuous
duct-like structures. The large, skipping
stone-like calcifications are scattered within
the ducts.
Fig. 106p
Fig. 106q
Practice in Calcification Analysis
225
Histology
Fig. 106 s: Subgross, 3D histology image of
the tightly packed, distended ducts. Neoangioneogenesis is seen around the cancerous
ducts.
Fig. 106 t: Large thin-section histology: the
cancerous, fluid-filled ducts and their
branches occupy an entire lobe.
Fig. 106 u, v: Low-power microscopic images of two duct-like structures with micropapillary carcinoma in situ, periductal desmoplastic reaction, and lymphocytic infiltration. The ducts are distended by fluid
produced by the micropapillary cancer cells.
The “skipping stone-like” calcification is
marked with an arrow.
Fig. 106 w, x: Subgross (3D) (w) and conventional (x) histologic images of the micropapillary cancer in situ.
Final Histology Following Mastectomy
53 × 30 mm grade 3 micropapillary and cribriform in situ carcinoma. No invasion demonstrable. P0/1 (sentinel node without
malignancy).
Fig. 106r
Fig. 106s
Fig. 106t–x e
226
VI Calcifications on the Mammogram
Fig. 106t
Fig. 106u
Fig. 106v
Practice in Calcification Analysis
Fig. 106w
Fig. 106x
227
228
VI Calcifications on the Mammogram
107
This 50-year-old asymptomatic woman was
called back from mammography screening
for assessment of the multiple clusters of
calcifications in the axillary tail of the right
breast.
Physical Examination
No palpable abnormality.
Fig. 107a
Mammography
Fig. 107 a, b: Right breast, detail of the MLO
projection (a) and photographic enlargement of the region with calcifications in
the axillary tail. Multiple clusters of powdery calcifications are seen with no associated tumor mass.
Fig. 107 c: Microfocus magnification view in
the LM horizontal projection. The calcifications are grouped in multiple clusters. Most
of the individual calcification particles are
distinguishable, contrary to the appearance
of powdery/cotton-ball-like calcifications.
No associated tumor mass is seen.
Fig. 107b
Fig. 107 d: Hand-held ultrasound: an irregular hypoechoic area is demonstrable in the
axillary tail, corresponding to the region
with the multiple clusters of calcifications
on the mammogram.
Analysis
(best on the magnification views)
Distribution: multiple clusters in a confined
region of the axillary tail
Form: powdery/cotton ball-like on the nonmagnification images, but it is a mixture of
both powdery and crushed stone-like calcifications on the microfocus magnification
images
Density: the cotton ball-like calcifications
are faint; the crushed stone-like particles
vary in density.
Practice in Calcification Analysis
229
Fig. 107c
Fig. 107d
Fig. 107e–t e
230
VI Calcifications on the Mammogram
Conclusion
The mixture of crushed stone-like/pleomorphic and powdery calcifications suggests a
multifocal malignant process. Microscopic
diagnosis of the tissue surrounding the calcifications is necessary. Percutaneous stereotactic large-bore needle biopsy can provide this, but benign surgical biopsy is recommended because of the high probability
of malignancy.
Fig. 107 e: Radiographs of the ultrasoundguided percutaneous large-bore needle biopsy specimens. Numerous calcifications
are contained in the two specimens.
Fig. 107 f–h: Histology of the percutaneous
large-bore needle biopsy: fibrocystic
change, benign intraductal papilloma and
grade 1 in situ carcinoma.
Fig. 107 i: Operative specimen radiograph.
The multiple clusters of calcifications detected on the mammogram have been removed surgically.
Fig. 107 j: Subgross (3 D) histology of one of
the specimen slices. The area corresponding
to the multiple clusters of calcifications described on the mammogram is encircled.
Fig. 107 k: Low-power, large-format, thinsection histologic image of the area corresponding to that shown on Fig. 107 j.
Fig. 107 l–n: The tightly packed distended
acini contain cancer cells, fluid, and calcifications.
Fig. 107e
Fig. 107f
Practice in Calcification Analysis
Fig. 107g
231
Fig. 107h
Fig. 107i
Fig. 107j–t e
232
VI Calcifications on the Mammogram
Fig. 107j
Fig. 107k
Practice in Calcification Analysis
233
Fig. 107l
Fig. 107m
Fig. 107n
Fig. 107o–t e
234
VI Calcifications on the Mammogram
Fig. 107 o–r: The cancer cells growing
within the acini produce highly proteinaceous fluid, within which large calcification
particles (arrows) have been formed. They
are spherical, oval-shaped, generally with
smooth contours (“skipping stone-like calcifications”). They are extremely tiny because they are formed within the individual
acini of the TDLU. Skipping stone-like calcifications produced by the same mechanism
within the ducts will be much larger. The
mammographic presentation of these calcifications can be seen on the specimen radiograph in Fig. 107 i.
Fig. 107 s: Subgross (3D) histology with
clusters of calcifications (rectangle) and a
large papilloma (solid arrow).
Fig. 107 t: Low-power thin-section histology image of the benign papilloma containing microcalcifications similar to those associated with the cancer. The similarity of
the calcifications in Fig. 107 s, t with the
calcifications in Fig. 107 o–r demonstrates
the difficulties encountered when analyzing
the mammographic image.
Fig. 107o
Histology
25 × 20 mm grade 1 and grade 2 in situ carcinoma with no signs of invasion.
Fig. 107p
Fig. 107q
Practice in Calcification Analysis
235
Fig. 107r
Fig. 107s, t e
236
VI Calcifications on the Mammogram
Fig. 107s
Fig. 107t
Practice in Calcification Analysis
108
237
A 43-year-old woman referred for a recently
detected lump in the upper outer quadrant
of the right breast. The tumor was clinically
suspicious for malignancy.
Analysis of the Calcifications
Distribution: a large cluster within a tumor
mass
Form: irregular, a mixture of crushed stonelike/pleomorphic and casting-type calcifications
Size: varies from barely visible particles to
long casts
Density: varies considerably
Histology
Poorly differentiated, invasive ductal cancer
associated with high-grade in situ carcinoma. Axillary lymph node metastases
were present.
Fig. 108 c: Low-power histologic image
showing part of the invasive tumor to the
right and the in situ components to the left
(H&E, 40 ×).
Mammography
Fig. 108 a, b: Right breast, MLO projection,
contact mammogram and microfocus magnification. A cluster of calcifications is seen
associated with a tumor mass.
Conclusion
Mammographically typical picture of malignant-type, crushed stone-like/pleomorphic
and casting-type calcifications, associated
with an ill-defined, palpable tumor mass.
Follow-up
The patient died 7 years later of metastatic
breast carcinoma, aged 50 years.
Fig. 108a
Fig. 108b
Fig. 108c
238
VI Calcifications on the Mammogram
109
A 77-year-old asymptomatic woman. First
screening study.
Mammography
Fig. 109: Detail of the CC projection. Microfocus magnification of the retroareolar region. There is a retroareolar tumor with
coarse associated calcifications; 1 cm medial to the tumor there is a small cluster of
calcifications without a tumor mass (arrows).
Analysis of the Tumor
Form: oval, lobulated
Contour: unsharp
Density: low-density radiopaque
Analysis of the Intratumoral Calcifications
Distribution: within and immediately adjacent to the tumor mass
Form: irregular, coarse
Size: variable
Density: high
Conclusion
Mammographically benign-type calcifications within a tumor mass of low density.
Most probably a calcified fibroadenoma.
Analysis of the Calcifications Adjacent to the
Tumor
Distribution: cluster
Form: irregular, branched, elongated, fragmented casting-type
Density: variable within the same elongated
calcification
Conclusion
Fragmented casting-type calcifications, typical for high-grade intraductal cancer.
Histology
The tumor mass with calcifications corresponds to a partially calcified fibroadenoma.
The fragmented casting-type calcifications
were localized within high-grade in situ
carcinoma associated with a small invasive
ductal cancer.
Fig. 109
Benign-type Calcifications within Ducts or Lobules
Benign-type Calcifications within Ducts
or Lobules
Benign-type Calcifications Arising
within Ducts and their Branches
Secretory disease-type/plasma cell mastitistype calcifications are the most frequently
occurring intraductal calcifications. The
proteinaceous fluid produced by the TDLUs
accumulates within the ducts. This inspissated material may calcify, resulting in linear intraductal calcifications with regular
form, smooth contour, and a high uniform
density (Case 118). These needle-like calcifications are bilateral, they point toward the
nipples, and reflect the branching structure
of normal breast ducts. The only malignant
breast disease with similar linear/branching
calcifications on the mammogram is the
high-grade cancer in situ with fragmented
casting-type calcifications. The malignanttype intraductal calcifications are unilateral,
localized only to one lobe, and the individual calcifications are tightly packed, point in
all different directions, and are irregular in
contour and density.
When the inspissated proteinaceous material in secretory disease filters through the
duct wall, it initiates a fibrous reaction,
which encases the fluid and the duct segments. In addition, the resulting immune
reaction contains a large number of plasma
cells, hence the term “plasma cell mastitistype calcifications.” The resulting calcifications on the mammogram are ring-like,
elongated, oval, branching, sharply outlined,
and smoothly contoured with central lucencies, indicating that they are periductal
(Cases 117, 125).
Papillomas and multiple papillomas are
solitary or multiple intraductal papillary
growths with a central fibrous stalk and a
delicate blood supply that may undergo torsion, resulting in hyalinization and calcification. The mammographic appearance of the
calcifications may be either:
• coarse, circular/oval with small lobulations (resembling a raspberry), high and
uniform in density, although they may
contain small lucent areas (Cases 127,
128, 130–132)
• irregular microcalcifications in a cluster
resembling the crushed stone-like/pleomorphic calcifications in grade 2 in situ
carcinoma within the TDLU.
Benign-type Calcifications Arising
within Terminal Ductal Lobular
Units (Lobules)
Careful analysis of the imaging findings narrows the differential diagnosis of clustered
calcifications on the mammogram to clearly
benign cases versus those that require microscopic diagnosis. Analysis of the following criteria will assist in patient management:
• distribution of the calcifications: normal
and cystically dilated TDLUs are demon-
239
strated by subgross (3D) histology in
Figs. 110 a and 111 a and in Figs. 110 b and
111 b, respectively. The individual TDLUs,
both normal and distended, are separated
from each other by the intervening connective tissue. Each lobule containing
multiple calcification particles forms a
single cluster. Thus, the calcifications
(benign or malignant) arising within one
or more lobules will appear on the mammogram as a cluster/multiple clusters
• form/shape of the calcifications: the most
frequently occurring benign-type calcifications arise within lobules that have
been altered by any of the following hyperplastic breast changes: fibrocystic
change, sclerosing adenosis, blunt duct
adenosis.
Fig. XXVIII a–f Schematic presentation of various types
of calcifications within altered TDLUs:
a
Normal lobule.
b, c Skipping stone-like calcifications within fibrocystic
change.
d
Psammoma body-like calcifications in sclerosing
adenosis.
e, f Teacup-like calcifications in fibrocystic change.
240
VI Calcifications on the Mammogram
In fibrocystic change, the accumulating
fluid, produced by apocrine metaplasia, distends the TDLU(s). Within this fluid, three
different types of calcifications may occur:
• psammoma body-like calcifications may
form sediments. When the freely mobile
particles within the “milk of calcium”
settle to the dependent portion of the tiny
cystic cavities, they are seen on the lateral
view as crescent-shaped or elongate calcifications, which may resemble a teacup
seen from the side. These have a high
density on the LM horizontal projection
(Fig. XXVIIIe, f).5,6 On the CC view the
summation of the psammoma body-like
calcifications results in circular, faint,
opaque smudges. Occasionally, the entire
contents of the cavity may also solidify,
producing homogenous, evenly scattered, individually discernible, sharply
outlined, spherical calcifications (Cases
112, 113)
• calcium oxalate crystals, termed weddelites, may precipitate within the cystically
dilated acini.7 These are more easily discernible on digital mammograms (Cases
115, 119, 121) because they are octahedrons appearing as diamond-shaped or
spearhead-like calcifications. These birefringent crystals are best visualized
under the microscope using polarizing
filters
• large, “skipping stone-like” calcification
particles arise within the gradually concentrating proteinaceous cyst fluid in the
dilated TDLUs. These calcifications may be
erroneously termed “amorphous” at histologic examination, although they differ
considerably from the truly amorphous
calcifications occurring in high-grade
carcinoma in situ, because they are not
surrounded by the necrotic cell nuclei.
The makeup of the “skipping stone-like”
calcifications within the cystically dilated
acini in fibrocystic change is similar in
structure to that of the skipping stone-like
calcifications observed with fluid-producing micropapillary cancer in situ in
the ducts. It is desirable to distinguish the
benign skipping stone-like calcifications
within the TDLUs, associated with fibrocystic change (they are clustered) from the
skipping stone-like calcifications found in
micropapillary ductal cancer in situ (they
are usually scattered within a single lobe).
Thus, thorough analysis of the distribution of the calcifications might help,
although microscopic confirmation is always necessary. On the other hand, the
distinction between the discernible, often
bullet-shaped, clustered calcifications occurring in fibrocystic change versus the
similarly shaped and clustered microcalcifications in grade 2 in situ carcinoma
may not be possible with imaging alone,
and requires percutaneous stereotactic
large-bore needle biopsy. The differential
diagnostic difficulty is caused by the
similarity in the shape/density/size/distribution of the calcifications arising from
two different diseases.
In sclerosing adenosis there may be innumerable psammoma body-type calcifications developing in the proliferating and
elongated acini that are squeezed by the
proliferating intralobular connective tissue.
The individual acinar calcifications appear
on the mammogram as multiple clusters of
typical powdery/cotton ball-like calcifications (Cases 95, 120) (Fig. XXVIIId). These
are mammographically indistinguishable
from those associated with grade 1 in situ
carcinoma, although the mechanism producing them is entirely different. The cancer
cells in grade 1 in situ carcinoma produce a
mucous fluid within which the psammoma
body-like calcifications may be formed.
These cannot sediment within the viscous
fluid, and appear on the mammogram as
multiple clusters of powdery/cotton balllike calcifications (Cases 97, 98, 107).
Comment
When the mammogram shows considerable fibrosis and scattered calcifications
that are either diamond-shaped or teacuplike, such calcifications have been produced
in the fluid associated with fibrocystic
change. No further procedures are indicated
other than microfocus magnification images
in two orthogonal projections, especially
when the calcifications are scattered over
a large area or in both breasts. If they are
clustered/multiple clustered and the analysis of the shape/density of the calcifications
causes differential diagnostic problems, percutaneous large-bore needle biopsy will be
necessary. Histologic examination may then
reveal some degree of epithelial cell proliferation either close to the microcalcifications or elsewhere.
Benign-type Calcifications within Ducts or Lobules
110, 111
In these two examples, the subgross (3D)
histology images demonstrate normal ducts
and TDLUs (Figs. 110 a and 111 a) and their
Fig. 110a
distension/distortion caused by the fluid accumulated in fibrocystic change (Figs. 110 b
and 111 b). In this fluid, the three different
types of calcifications described earlier
(p. 240) may occur, causing a differential
diagnostic problem when the mammographic findings are analyzed.
Fig. 110b
Fig. 111a
Fig. 111b
241
Figs. 110 a and 111 a: Normal ducts and
TDLUs.
Figs. 110 b and 111 b: The cystically dilated
lobules have become saccular, fluid-filled
cavities, within which the different types
of calcifications characteristic of fibrocystic
change are formed.
242
VI Calcifications on the Mammogram
Miscellaneous Calcifications
Arterial Calcifications
Sebaceous Gland Calcifications
Arterial calcifications are usually easy to
recognize because the calcified arterial
walls have a typical radiological appearance. When calcification is sparse, it may
be difficult to recognize the arterial origin
of these intermittent calcifications (Case
123).
These are easily recognized and should not
lead to confusion (Case 124). There are two
characteristic mammographic appearances,
depending upon whether calcification
arises within the wall of the sebaceous
gland (ring-like, hollow) or within the cavity (high-density, punctate).
Distribution: occur only within the skin
and often numerous
Periductal Mastitis/Plasma Cell
Mastitis
Calcifications resulting from periductal
mastitis produce a typical mammographic
appearance. This condition results from extravasation of intraductal secretions, causing a periductal chemical mastitis. This sterile inflammatory reaction is characterized
by the presence of plasma cells surrounding
the dilated duct. Periductal fibrosis and intraductal and/or periductal calcifications
are the final result (Cases 117, 125).
Distribution: multiple, most often bilateral, scattered, oriented toward the nipple,
following the course of the ducts
Form: a calcified ring surrounds the dilated duct; when the calcification extends
around and along the duct, it appears oval
or elongated. Fibrosis accompanies these
hollow calcifications (Cases 117, 125)
Density: both ring and elongate forms
have a center of varying lucency, corresponding to the lumen of the duct. The calcifications themselves are very dense
Involutional-type Calcifications
These high-density, round, dot-like calcifications are evenly scattered within an affected lobe and may be bilateral. When the
glandular tissue undergoes atrophy, the
supporting interlobular fibrous tissue may
proliferate and protrude into the duct walls,
forming tiny invaginations that eventually
result in spherical calcifications (Cases 116,
122, 141). These calcifications are frequently found on screening mammograms.
An understanding of their origin and familiarity with their mammographic appearance can avoid unnecessary intervention
in these cases.
Eggshell-like Calcifications
Oil Cysts
(Cases 4, 129, 133–135, 139, 140)
Following trauma to the breast, blood may
collect within a smaller or larger spherical
or ovoid cavity. Enzymes from the blood
decompose necrotic adipose tissue to oil
(glycerin) and fatty acids. A fibrotic capsule
will surround the oil-filled cavity. Calcium
soaps are eventually formed at this capsular
surface, resulting in a thin layer of calcification surrounding the oil cyst. The combination of the radiopaque calcification and the
radiolucent oil content give an eggshell-like
appearance on the mammogram.
Form: spherical or oval
Size: variable, from 1 millimeter up to
several centimeters
Density: the calcification progresses from
a very thin and intermittent layer to a highdensity sphere. The characteristic eggshelllike appearance makes the mammographic
picture unmistakable
Cysts with Eggshell-like Calcification
A cyst with eggshell-like calcification is a
rare finding and, unlike the oil cyst, has a
radiopaque center. The eggshell-like calcifications surrounding a cystic cavity are thin
and almost invariably benign (Case 136).
The rare exception is a smaller retroareolar
eggshell-like calcification, which may represent calcified blood surrounding a benign intracystic papilloma or intracystic
papillary carcinoma (Case 137).
Fibroadenomas with Eggshell-like
Calcification
A fibroadenoma with eggshell-like calcification is rare. This also has a radiopaque center but the calcifications are coarse and
dense. The mammographic image is highly
characteristic and no intervention is necessary (Case 138).
Types of Calcifications in Fibroadenomas
Fibroadenomas may present with four different types of calcification, some of which
may cause differential diagnostic problems:
• small, discernible, clustered crushed
stone-like/pleomorphic calcifications
within a fibroadenoma may mimic the
appearance of calcifications occurring in
grade 2 in situ carcinoma. Core needle
biopsy can resolve this dilemma (Cases
145–149)
• coarse, irregular but sharply outlined,
very dense calcification. This popcornlike appearance is diagnostic of an old
fibroadenoma which has undergone
myxoid degeneration. The calcification
may involve part or all of the fibroadenoma (Cases 142–144)
• peripheral calcifications in a fibroadenoma may take the appearance of an
eggshell (see above) (Cases 138, 150)
• malignant-type calcifications associated
with a fibroadenoma (Case 103).
Hemangiomas
Hemangiomas may present with either
small calcifications that vary in form and
size, or with larger, bizarre calcifications
(Cases 23, 151).
Warts
Warts may, rarely, calcify. Those that do
may be deceptive on the mammogram, but
are obvious on inspection (Case 152).
Practice in Calcification Analysis
Practice in Calcification
Analysis
112
(Cases 112–152)
A 43-year-old woman with breast pain and
grayish secretion from several ducts of the
right breast.
Mammography
Fig. 112: Right breast, detailed view of the
CC projection (microfocus magnification
view).
Numerous calcifications of varying size are
scattered within the fibrous tissue.
Note: See Figs. 110 b and 111 b, where distended lobules are demonstrated on subgross (3D) histology.
Fig. 112
243
Analysis of the Calcifications
Distribution: scattered in a lobe
Form: spherical, some lobulated, taking the
shape of the cystically dilated TDLUs. The
largest calcifications are septated
Size: variable, depending on the cystically
dilated TDLUs
Density: faint, uniform
Conclusion
The septated, smooth-contoured low-density calcifications scattered within a lobe
and surrounded by extensive fibrosis correspond to the 3D histologic image of fibrocystic change in Figs. 110 b and 111 b.
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VI Calcifications on the Mammogram
113
A 52-year-old woman, first screening study.
Previous biopsy of the right breast. No palpable tumor.
Mammography
Fig. 113 a: Right breast, MLO projection.
There is extensive fibrosis over much of
the breast, with numerous calcifications.
No tumor is seen.
Fig. 113 b: Microfocus magnification view,
MLO projection. There are three different
kinds of calcifications.
Analysis of the Calcifications
This is best on the magnification view
(Fig. 113 b):
• the linear calcifications (solid arrows)
correspond to the site of operation. They
are smooth-bordered and highly dense
and appear to be benign, possibly calcified
sutures
• the punctate calcifications (open arrow)
are small, round, and sharply outlined,
with uniform density. These are localized
within distended acini and are of the
mammographically benign type
• there are several crescent-shaped, teacuplike calcifications situated in the dependent, caudal portions of cystically dilated
lobules (curved arrows).
Fig. 113a
Conclusion
The mammographic image of fibrocystic
change includes extensive fibrosis associated with scattered pearl-like and teacuplike calcifications. When these are the only
mammographic findings, there should be
no indication for needle biopsy or surgical
intervention.
Fig. 113b
Practice in Calcification Analysis
245
114
An asymptomatic 42-year-old woman. First
screening study.
Physical Examination
No tumor is palpable in the breasts.
Mammography
Fig. 114 a: Right breast, LM projection. Numerous calcifications scattered throughout
the breast. No associated tumor.
Fig. 114 b: Right breast, microfocus magnification view, LM projection.
Fig. 114 c: Operative specimen radiograph.
Analysis of the Calcifications
Distribution: scattered throughout much of
the breast
Form: crescent-shaped, teacup-like
Density: uniform, fairly high
Fig. 114a
Conclusion
This is a typical mammographic appearance
of the benign-type calcifications seen in fibrocystic change. The crescent-shaped calcifications (Fig. 114 b) appear to resemble a
teacup seen from the side. These same calcifications appear circular and smudgy on
the specimen radiograph (taken with a vertical X-ray beam) and resemble sediments
within a teacup seen from above.
Histology
Fibrocystic change with no epithelial cell
proliferation or atypia.
Fig. 114 d: Cystically dilated acini containing
milk of calcium secretions (H&E, 40 ×).
Comment
In the late 1970s, many such cases were sent
to operation, providing the opportunity for
detailed histologic–mammographic correlation. These teaching cases have taught us
that these characteristic mammographic
findings are not an indication for surgery.
Fig. 114b
Fig. 114c, d e
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VI Calcifications on the Mammogram
Fig. 114c
Fig. 114d
Practice in Calcification Analysis
115
This 42-year-old asymptomatic woman was
called back from mammography screening
for evaluation of the microcalcifications detected on her mammograms.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 115 a–d: Details of the right and left
MLO (a, b) and CC (c, d) projections. There
are a large number of microcalcifications
scattered throughout both breasts. No dominant tumor mass is demonstrable.
Fig. 115 e: Microfocus magnification.
247
Analysis of the Calcifications
Distribution: scattered
Form: sharply outlined, many rectangular
and diamond-shaped
Density: high, variable (equal-sized calcifications are of similar density)
Fig. 115a
Fig. 115b
Fig. 115c
Fig. 115d
Fig. 115e e
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VI Calcifications on the Mammogram
Conclusion
This is a typical picture of calcium oxalate
crystals (weddelites). These calcifications
have been formed within cystically dilated
TDLUs in fibrocystic change. When the weddelites are diffusely scattered in both
breasts, the mammographic diagnosis is fibrocystic change, and interventional procedures are not indicated.
Fig. 115e
Practice in Calcification Analysis
249
116
A 59-year-old asymptomatic woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 116 a, b: Right breast, MLO and CC projections. A large group of unilateral calcifications is seen centrally in the breast, with
no associated tumor mass.
Fig. 116 c, d: Right breast, microfocus magnification views, MLO and CC projections.
Analysis
Distribution: scattered within one lobe
Form: punctate, sharply outlined
Density: high, little variation
Size: variable, mostly very small
Conclusion
Typical appearance of involutional-type calcifications, mammographically benign.
Fig. 116a
Histology
Involutional-type calcifications. No signs of
malignancy.
Comment
Experience with thorough mammographic–
histologic correlation of this, and similar
cases, has taught us that such involutionaltype calcifications need not be biopsied,
since the analysis of microfocus magnification images is usually sufficient for definitive diagnosis.
Fig. 116b
Fig. 116c, d e
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VI Calcifications on the Mammogram
Fig. 116c
Fig. 116d
Practice in Calcification Analysis
117
Asymptomatic 65-year-old woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 117: Left breast, MLO projection. Numerous calcifications scattered throughout
the breast. No associated tumor.
Analysis
Distribution: follow the normal course of
the ducts
Form: elongated, branching, some needlelike. There are also a few ring-like and
oval, hollow calcifications. All are sharply
outlined and smooth bordered
Density: high. Those with central lucencies
are periductal. The intraductal calcifications
are homogeneously calcified
Conclusion
This is a typical picture of secretory disease/
plasma cell mastitis-type calcifications,
both intraductal and periductal forms.
Fig. 117
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118
An asymptomatic woman, aged 64 years.
First screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 118 a: Left breast, CC projection. In the
central portion of the breast there is an
approximately 6 × 6 cm area containing numerous calcifications. No associated tumor.
Fig. 118 b, c: Microfocus magnification
views, CC and MLO projections.
Fig. 118a
Analysis of the Calcifications
Distribution: some appear to follow the
course of a duct
Form: mostly elongated, sharply outlined,
smooth bordered; some are needle-like
Density: high; some have a lucent central
area (periductal calcifications), but most
are homogenous in density (solid, intraductal calcifications)
Size: variable in length
Conclusion
This appearance is of the rarely seen variety
of plasma cell mastitis, in which the intraductal fluid petrifies and renders segments
of the duct visible.
Fig. 118b
Fig. 118c
Practice in Calcification Analysis
119
A 43-year-old asymptomatic woman called
back from screening for further assessment
of the mammographically detected bilateral
microcalcifications.
Fig. 119a
Mammography
Fig. 119 a–c: Photographic magnifications of
details from the MLO projections (a, b) of
the right and left breasts. Fig. 119 c is an
inverse image of Fig. 119 b. Scattered calcifications are seen against the background of
dense fibroglandular tissue. No dominant
tumor mass is demonstrable.
253
Fig. 119 d–g: Details of the right and left CCl
projections (d, e). Fig. 119 f, g are inverse
images of Fig. 119 d, e.
Analysis of the Calcifications
Distribution: scattered bilaterally
Form: sharply outlined, many rectangular
and diamond-shaped, typical of calcium oxalate crystals, which are octahedrons, wed-
Fig. 119b
Fig. 119c
Fig. 116d–g e
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VI Calcifications on the Mammogram
dellites. Inverting the images can assist the
radiologist in analyzing the details of the
calcifications
Density: high, variable (equal sized calcifications are of similar density)
Comment
When mammography clearly demonstrates
bilaterally scattered weddelites, the underlying hyperplastic breast change contains
small cystic dilatations of the TDLUs, surrounded by fibrosis (fibrocystic change).
Fig. 119d
Fig. 119e
Fig. 119f
Fig. 119g
Hand-held ultrasound can readily identify
the numerous tiny cystic cavities, many of
which will contain calcium oxalate crystals.
The use of Doppler will cause the calcification to move within the fluid, further confirming the diagnosis.
Practice in Calcification Analysis
120
This 51-year old asymptomatic woman was
called back from mammography screening
for assessment of the microcalcifications
detected on her mammograms.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 120 a, b: Right and left breasts, CC projections. Multiple clusters of powdery calcifications are seen bilaterally against a dense,
Fig. 120a
fibrous background. No tumor mass is demonstrable.
Fig. 120 c–e: Microfocus magnification images of different regions of the right breast
demonstrate clusters of powdery calcifications.
Fig. 120 f: Operative specimen radiograph: a
representative sample has been surgically
removed.
Analysis of the Calcifications
Distribution: bilaterally scattered throughout the breasts
Form: powdery, cotton ball-like
Density: faint
255
Conclusion and Comment
The powdery, cotton ball-like calcifications
without associated tumor mass occurring in
sclerosing adenosis are mammographically
indistinguishable from those associated
with grade 1 in situ carcinoma, necessitating thorough microscopic examination,
preferably following surgical biopsy. In sclerosing adenosis, the psammoma body-type
calcifications are localized in the proliferating and elongated acini that are squeezed by
the proliferating intralobular connective tissue. The summation of the tiny individual
acinar calcifications appears on the mammogram as a cluster of powdery/cotton
ball-like calcifications.
Fig. 120b
Fig. 120c–r e
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VI Calcifications on the Mammogram
Fig. 120c
Fig. 120d
Fig. 120e
Fig. 120f
Practice in Calcification Analysis
Histology
Sclerosing adenosis, fibrocystic change with
apocrine metaplasia. No evidence of malignancy.
Fig. 120g
Fig. 120i
Fig. 120 g, h: Large-section histology image
(g) and a low-power microphotograph (h)
provide an overview of the findings.
Fig. 120 i–r: Mammographic–histologic correlation demonstrates that the powdery cal-
257
cifications detected on the mammograms
correspond to psammoma body-like calcifications localized in benign sclerosing adenosis at histologic examination. No atypia
and no evidence of malignancy is seen.
Fig. 120h
Fig. 120j
Fig. 120k–r e
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VI Calcifications on the Mammogram
Fig. 120k
Fig. 120l
Fig. 120m
Fig. 120n
Fig. 120o
Fig. 120p
Practice in Calcification Analysis
Fig. 120q
Fig. 120r
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VI Calcifications on the Mammogram
121
This 47-year-old asymptomatic woman was
called back from mammography screening
for further assessment of the microcalcifications detected on her mammograms.
There are scattered calcifications over a
background of dense fibrosis.
Analysis
Distribution: scattered
Form: due to the overlying dense fibrosis,
the shape of the individual calcifications is
difficult to determine
Density: varies depending on projection
Size: variable
Conclusion
There is a differential diagnostic difficulty in
distinguishing skipping stone-like calcifications associated with extensive micropapillary cancer in situ versus calcium oxalate
crystals seen in fibrocystic change.
Fig. 121 d–h: The higher-resolution images
of the specimen slices clearly show a large
number of octahedron-shaped, calcium oxalate crystals, so-called weddelites.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 121 a–c: Detail of the right MLO projection (a), microfocus magnification on the
LM horizontal (b) and CC (c) projections.
Fig. 121a
Fig. 121b
Fig. 121c
Practice in Calcification Analysis
Fig. 121d
Fig. 121f
261
Fig. 121e
Fig. 121g–k e
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VI Calcifications on the Mammogram
Histology
Fibrocystic change with no signs of malignancy.
Fig. 121 i–k: Histology: fibrocystic change,
microphotographs of the H&E-stained
specimen (i–k). The calcium oxalate crystals
have the same structural appearance as in
the specimen radiographic images.
Fig. 121g
Fig. 121h
Practice in Calcification Analysis
Fig. 121i
Fig. 121j
Fig. 121k
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VI Calcifications on the Mammogram
122
First screening examination of a 52-year-old
asymptomatic woman.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 122 a, b: Right breast, MLO projection,
contact (a) and microfocus magnification
(b) views. There is a 4 × 2 cm area of numerous microcalcifications in the upper half of
the breast. No associated tumor.
Analysis of the Calcifications
Distribution: lobar
Form: punctate, smooth contour
Density: high, uniform
Size: small, variable
Fig. 122a
Conclusion
Mammographically typical appearance of
benign, involutional-type calcifications.
Fig. 122b
Practice in Calcification Analysis
123
An 81-year-old asymptomatic woman. First
screening study.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 123 a: Left breast, MLO projection. There
are three findings: a small, centrally located
oval density with a hollow center, retroareolar calcifications, and arterial calcifications.
Fig. 123 b, c: Enlarged views of the centrally
located oval density (b) and the retroareolar
region with the calcifications (c).
Analysis of the Density
Form: oval
Contour: sharply outlined
Density: radiolucent and radiopaque combined
Size: 9 × 7 mm
Fig. 123a
Conclusion
This description is typical of an intramammary lymph node.
Analysis of the Calcifications (arrows)
Distribution: follows the course of the ducts
Form: elongated, not fragmented
Density: high, uniform; no hollow center
Size: length variable, up to 15 mm
Conclusion
Typical appearance of secretory disease/
plasma cell mastitis-type calcifications.
Fig. 123c
Fig. 123b
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124
A 70-year-old asymptomatic
Screening study.
woman.
Physical Examination
No tumor palpable in the breasts.
Mammography
Fig. 124 a, b: Left breast, two images in the
MLO projection: numerous scattered calcifications are seen without an associated tumor mass.
Fig. 124 c: Microfocus magnification view.
Analysis
Two types of calcifications are present:
• the periductal calcifications near the nipple (arrows) are sharply outlined, and
have a high density. These are the plasma
cell mastitis-type calcifications
• calcifications seen throughout the mammograms.
Distribution: intradermal
Form: ring-like, oval
Density: low, lucent center
Size: same as the sebaceous glands
Comment
The ring-like oval calcifications are typical
of calcified sebaceous glands. This unmistakable appearance should not lead to confusion.
Fig. 124a
Practice in Calcification Analysis
Fig. 124b
Fig. 124c
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VI Calcifications on the Mammogram
125
First screening study of a 62-year-old
asymptomatic woman.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 125 a, b: Left breast, MLO and CC projections. There is a group of calcifications in
the lower half of the breast, with no associated tumor.
Fig. 125 c: Microfocus magnification view,
CC projection.
Analysis of the Calcifications
Distribution: localized to a small area, apparently following the course of a duct
Form: irregular, some elongated
Density: high, nearly all have central lucencies, indicating that they are periductal. The
remainder are uniformly calcified
Fig. 125a
Conclusion
Typical mammographic appearance of secretory disease/plasma cell mastitis-type
calcifications. The case is unusual in that
the calcifications are unilateral and localized to a small region.
Fig. 125b
Fig. 125c
Practice in Calcification Analysis
126
A 52-year-old woman, referred for mammography because of cancerophobia.
Physical Examination
No abnormality at inspection or palpation.
Mammography
Fig. 126 a, b: Left breast, microfocus magnification views in the MLO and CC projections. Calcifications are scattered throughout the dense breast. A similar picture was
observed in the right breast.
Analysis of the Calcifications
Distribution: scattered throughout
dense parenchyma
Form: irregular, some are spherical
Density: high, somewhat variable
Size: small, variable
the
Conclusion
Calcifications this widely varying in form,
size, and density necessitate histologic examination because of a concern about fibrocystic change associated with epithelial cell
proliferation with or without atypia.
Fig. 126a
Histology
Fibrocystic change with atypical lobular hyperplasia. No evidence of malignancy.
Fig. 126b
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127
A 52-year-old asymptomatic woman. First
screening examination.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 127 a, b: Left breast, MLO and CC projections. Several calcified circular/oval densities are seen in the lower outer quadrant
of the breast.
Analysis of the Densities
Distribution: appear to lie within the duct
system of one lobe
Form: circular/oval, lobulated
Density: low density radiopaque
Size: variable, from 2 mm up to 2 cm
Fig. 127a
Conclusion
Multiple benign tumors, possibly in one
duct and its branches.
Analysis of the Calcifications
Distribution: within and surrounding the
densities
Form: irregular, shell-like
Density: larger calcifications very dense,
smaller calcifications of variable density
Conclusion
Partially calcified multiple benign lesions in
the course of one duct and its branches.
Histology
Multiple benign papillomas, some calcified.
Fig. 127b
Practice in Calcification Analysis
128
First screening study of a 65-year-old
asymptomatic woman.
Physical Examination
No palpable tumor in the breasts.
Mammography
Fig. 128 a: Right breast, CC projection: 5 cm
from the nipple there is an ill-defined density associated with a group of calcifications.
Fig. 128 b: Microfocus magnification view,
CC projection.
Analysis of the Density
Form: oval, lobulated
Contour: mostly ill-defined, microlobulated
Density: low-density radiopaque, equal to
that of parenchyma
Fig. 128a
Analysis of the Calcifications
Distribution: two groups near to each other;
one group is not associated with the tumor
Form: highly irregular, one is hollow. There
are a few needle-like calcifications between
the lesion and the chest wall, apparently
intraductal
Density: high, fairly uniform
Size: fairly large, variable
Histology
Multiple benign intraductal papillomas,
some of them calcified. No evidence of malignancy. The linear calcifications between
the lesion and the chest wall were formed
within calcified blood originating from the
papilloma.
Fig. 128b
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VI Calcifications on the Mammogram
129
Fig. 129: Five ring-like calcifications with
central lucencies. Sharply outlined, high
density, no associated tumor. Typical picture of calcified microhematomas (see oil
cysts above).
Fig. 129
Practice in Calcification Analysis
130
131
132
Figs. 130, 131, 132: Three typical mammographic appearances of totally calcified solitary intraductal papillomas.
Fig. 130
Fig. 131
Fig. 132
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VI Calcifications on the Mammogram
133
First screening study of an asymptomatic
44-year-old woman.
Physical Examination
No palpable tumor.
Mammography
Fig. 133 a, b: Right and left breasts, MLO
projections. Numerous calcifications are
seen throughout the breasts.
Analysis of the Calcifications
Distribution: many, if not all, of the calcifications lie within the subcutaneous fat
Form: circular
Size: from very small to 3 mm
Density: very dense calcifications with central radiolucencies
Conclusion
These calcifications with a radiolucent center are benign-type calcified microhematomas.
Fig. 133a
Fig. 133b
Practice in Calcification Analysis
134
History of a breast biopsy 15 years earlier.
Mammography
Fig. 134: Detailed view in the CC projection.
There are several large amorphous calcifications.
Analysis of the Calcifications
Distribution/location: near the site of surgery
Form: irregular, eggshell-like, sharply outlined
Density: high with numerous central radiolucencies
Size: variable, largest 5 × 3 cm
Fig. 134
Conclusion
The history of breast surgery, the location of
the calcifications at the surgical site, and the
presence of central radiolucencies within
the calcifications lead to the diagnosis of a
calcified oil cyst developing from a calcifying hematoma.
135
A 58-year-old woman, who underwent
plastic surgery to the breast 15 years earlier.
First screening examination.
Mammography
Fig. 135: Left breast, CC projection. A long
subareolar scar is seen adjacent to a calcified lesion.
Analysis
Distribution/location: at the site of surgery
Form: elongated, lobulated, eggshell-like
Size: 3 × 1 cm
Density: high, radiolucent center
Comment
Cysts, oil cysts, and fibroadenomas can all
have shell-like calcification, but only the oil
cyst has a radiolucent center.
Conclusion
Calcified oil cyst. The history of surgery
provides further evidence for this conclusion.
A small calcified oil cyst is located laterally
at the site of the surgical drain.
Fig. 135
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VI Calcifications on the Mammogram
136
Fig. 136: CC projection. There is a 7 × 6 mm
oval-shaped, circumscribed tumor centrally
in the breast (open arrow), with a calcified
rim (eggshell-like). This is a partially calcified cyst (radiopaque center). There is also a
solitary ring-like calcification (solid arrow)
(small calcified hematoma with a radiolucent center).
Fig. 136
Practice in Calcification Analysis
137
A 78-year-old woman, referred for a hard
retroareolar tumor, first noted 1 year earlier.
Mammography
Fig. 137 a, b: Right breast, MLO and CC projections. There is a solitary, calcified retroareolar tumor.
Analysis
Form: oval
Contour: sharply outlined, with eggshelllike calcification
Size: 15 × 20 mm
Comment
An eggshell-like calcified, oval/circular tumor can be either an oil cyst, a calcified
fibroadenoma, or a calcified cyst (with or
without an intracystic tumor).
• An oil cyst can be excluded in this case
because the contents are not radiolucent.
• A fibroadenoma has coarse calcifications
that differ considerably from this lesion
(Case 138).
• Cysts calcify in a manner similar to that of
this lesion. The thin, faintly calcified shell
is the result of bleeding. The bleeding may
result from an intracystic growth, especially in lesions located behind the nipple.
Needle biopsy helps in the final diagnosis.
Fig. 137a
Cytology
Malignant cells.
Histology
Subareolar papillary carcinoma.
Fig. 137b
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VI Calcifications on the Mammogram
138
A 56-year-old woman, referred to mammography for a calcification seen on the
chest X-ray. The patient has been aware of
this palpable tumor for many years.
Mammography
Fig. 138 a, b: Left breast, detailed views of
the MLO and CC projections. A large, calcified tumor is seen immediately behind the
nipple.
Analysis of the Tumor
Form: oval, lobulated
Contour: sharply outlined (arrows)
Density: low-density radiopaque, equal to
the parenchyma
Size: 3.5 × 3 cm
Location: retroareolar
Fig. 138a
Analysis of the Calcifications
Form: eggshell-like, coarse
Density: very high
Location: surround much of the tumor
Conclusion
On the basis of the above characteristics, the
tumor is mammographically benign. When
the eggshell-like calcifications are coarse
and the tumor is radiopaque, the mammographic image is typical of a fibroadenoma.
Histology
Calcified fibroadenoma.
Fig. 138b
Practice in Calcification Analysis
139
A 56-year-old woman, who underwent
plastic surgery 12 years earlier. The patient
has observed gradual nipple retraction on
the left side and has noticed a hard retroareolar tumor.
Mammography
Fig. 139 a, b: Left breast, microfocus magnification views in the MLO and CC projections. Calcifications surround several ovalshaped radiolucent lesions. There is associated retroareolar fibrosis with nipple retraction.
Conclusion
Eggshell-like calcifications and the history
of breast surgery lead to the unmistakable
diagnosis of a group of calcified, post-traumatic oil cysts.
Fig. 139a
Fig. 139b
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VI Calcifications on the Mammogram
140
Fig. 140: Plastic surgery to the breast 15
years earlier. There are several eggshelllike calcifications; the largest measures
15 mm. A scar (arrows) extends from the
largest calcification to the nipple. The calcified lesions have lucent centers, giving the
typical mammographic appearance of calcified hematomas (oil cysts).
141
Fig. 141: Detailed view of the MLO projection. Microfocus magnification. Numerous
calcifications are seen over an area several
centimeters across. There is no tumor mass.
Analysis
Distribution: scattered within a lobe
Form: punctate
Density: high, uniform
Size: extremely small, uniform
Conclusion
Mammographically benign (involutionaltype) calcifications.
Practice in Calcification Analysis
142
143
144
Figs. 142, 143, 144: Three examples of hyalinized fibroadenomas. The calcifications are
coarse, amorphous, sharply outlined, and of
extremely high density, situated within a
lobulated, low-density, radiopaque tumor.
The mammographic image is diagnostic
and no intervention is needed.
Fig. 142
Fig. 144
Fig. 143
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VI Calcifications on the Mammogram
145–149
Figs. 145, 146, 147, 148, 149: Although the
coarse, popcorn-like calcifications associated with fibroadenomas shown in cases
142–144 should cause no differential diagnostic problems, the small crushed stonelike/pleomorphic calcifications within fibroadenomas (Figs. 145–149) may easily
be confused with the pleomorphic calcifications seen in Grade 2 carcinoma in situ.
Large-core needle biopsy is of great help in
differential diagnosis.
Fig. 145a
Fig. 145b
Practice in Calcification Analysis
Fig. 146a
Fig. 146b
Fig. 147
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VI Calcifications on the Mammogram
Fig. 148 b: A sclerotic fibroadenoma with
extensive peripheral microcalcifications
near an artery (H&E, 12.5 ×).
Fig. 148 c: Higher magnification of one area
of calcified stroma (H&E, 40 ×).
Fig. 148a
Fig. 148b
Fig. 148c
Practice in Calcification Analysis
Fig. 149a
Fig. 149b
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VI Calcifications on the Mammogram
150
This 63-year-old woman noted a lump in
her right breast, below the areola, 6 months
earlier.
Physical Examination
Freely moveable 1 cm tumor, clinically benign.
Mammography
Fig. 150 a, b: Coned-down compression
views of the tumor, which is associated
with calcifications.
Analysis of the Tumor
Form: oval, slightly lobular
Contour: unsharp, no halo sign; there is a
small comet tail (arrows, Fig. 150 a)
Density: low-density radiopaque
Size: 10 × 10 mm
Fig. 150a
Analysis of the Calcifications
Distribution/location: retroareolar
Form: eggshell-like (partially)
Density: high, coarse, irregular
Conclusion
The calcifications are of the benign type
(reminiscent of a partially calcified fibroadenoma). The tumor, although of low density, is not sharply outlined and there is a
comet tail, necessitating histologic examination.
Histology
Carcinoma in an old, hyalinized fibroadenoma.
Fig. 150b
Practice in Calcification Analysis
151
A 61-year-old asymptomatic woman. First
screening examination.
Physical Examination
There is a hard, freely movable tumor in the
upper inner quadrant of the right breast.
The tumor has been present for 20 years;
the overlying skin is bluish.
Mammography
Fig. 151 a: Right breast, CC projection. A calcified tumor is seen in the upper inner
quadrant.
Fig. 151 b, c: Microfocus, magnification
coned-down spot compression views before
and after puncture.
Fig. 151a
Analysis of the Tumor
Form: oval, lobulated
Contour: fairly sharply outlined, with a partial halo sign seen
Density: high-density radiopaque
Size: large, 4 × 3 cm
Analysis of the Calcifications
Location: inside the lesion
Form: highly irregular
Density: high
Size: coarse, variable
Conclusion
The extremely high density and coarseness
indicate a benign character.
Fine Needle Aspiration
Several milliters of dark blood were aspirated. Note the defect at the site of puncture
in Fig. 151 c (arrows).
Fig. 151b
Cytology
Blood, no epithelial elements.
Histology
Calcified hemangioma. No evidence of malignancy.
Fig. 151c
287
288
VI Calcifications on the Mammogram
152
Fig. 152 a, b: Calcified wart in the MLO and
CC projections. The calcifications localized
within warts may be deceptive, but inspection should clarify the issue. Occasionally it
will be necessary to mark the wart with a
lead pellet on a repeat mammogram.
Fig. 152a
Fig. 152b
VII Thickened Skin Syndrome
of the Breast
290
VII
Thickened Skin Syndrome of the Breast
This is a syndrome produced by lymphedema, usually secondary to obstruction of
the axillary lymphatics (see Fig. XXIX).
Fig. XXIX Thickened skin syndrome: thickened skin over much or all of the breast, associated with
increased density and a reticular pattern.
Mammographic Appearance
Physical Examination
• The affected breast is larger and heavier
due to increased fluid content.
• There is obvious peau d’orange.
• Enlarged axillary lymph nodes are frequently palpable.
• The skin is inflamed in the so-called inflammatory carcinoma, in acute mastitis,
and frequently in abscesses.
Mammographic
Appearance
(Cases 153 and 154)
• The skin is obviously thickened, often
many times normal thickness. This occurs
initially and to the greatest extent in the
lower, dependent portion of the breast.
• The overall density of the breast is increased due to its high fluid content. In
comparison to the other breast, there is a
coarse reticular pattern on the mammogram.
Causes of Lymphedema
Lymphedema may be caused by the following:
• axillary lymphatic obstruction blocking
lymphatic drainage of the breast. This
may be secondary to:
— breast carcinoma metastases. An aggressive carcinoma may spread
throughout the breast and axilla (Case
153). A carcinoma may also be located
high in the axillary tail and metastasize
directly to the axillary lymph nodes
— primary malignant lymphatic diseases
(lymphomas, etc.)
— advanced gynecological malignancies
(ovarian, uterine), which may rarely
block primary lymphatic drainage in
the lesser pelvis.1 The lymph flow then
passes through the thoracohypogastric
collaterals, overloading the axillary
and supraclavicular lymphatic drainage (Case 154)
•
•
•
•
— advanced bronchial or esophageal carcinoma may cause blockage of the
mediastinal lymph drainage, also resulting in the thickened skin syndrome
of the breast(s).
lymphatic spread of breast carcinoma
cells from the mastectomy side towards
the opposite breast. Such spread blocks
intradermal and intramammary lymph
channels in the remaining breast
retromamillary disease processes causing
blockage of the lymphatic plexus of Sappey. Both cancer and inflammation may
produce skin thickening over the areola
and the lower portion of the breast in the
absence of axillary lymphedema. Differentiation of inflammation from malignancy may be difficult in the absence of
imaging
inflammation, particularly large retromammillary abscesses that may produce
skin thickening over the areola and the
lower part of the breast. An important
differentiating factor is that the axillary
portion of the breast does not then show
the reticular pattern on the mammogram
(Cases 38, 42)
right heart failure, chonic renal failure,
anasarca. This may be restricted to the
dependent breast in a bedridden patient
lying on one side.
291
292
VII
Thickened Skin Syndrome of the Breast
153
A 62-year-old woman noted an increase in
size of her right breast over the past
6 months.
Physical Examination
The right breast is erythematous, heavy,
and remarkably larger than the left. There
is peau d’orange, and an enlarged axillary
lymph node is palpable. The left breast is
normal.
Mammography
Fig. 153: Right breast, craniocaudal (CC)
projection. Extreme skin thickening over
the entire breast. Extensive, prominent reticular pattern. No localized tumor. No associated calcifications.
Conclusion
An extensive reticular pattern reflects
lymphedema resulting from obstruction of
the axillary lymphatics. Massive lymphedema usually results from axillary lymphatic obstruction by malignant disease. In
the absence of a tumor mass, one should
suspect a diffusely infiltrating malignant
breast tumor.
Histology
Diffusely infiltrating breast carcinoma.
Metastases to the axillary lymph nodes.
Mammographic Appearance
154
A 72-year-old woman with metastatic ovarian carcinoma that was operated and irradiated four months earlier.
Physical Examination
The patient now has enlarged, hard axillary
and supraclavicular lymph nodes. Both
breasts are heavy and erythematous with
peau d’orange.
Mammography
Fig. 154 a: Left breast, mediolateral oblique
(MLO) projection.
Fig. 154 b: Right breast, CC projection.
There is extreme bilateral skin thickening,
increased radiopacity, and extensive reticular pattern throughout both breasts. There
is no localized tumor and no associated calcifications.
Conclusion
The history is crucial in this case. Advanced
gynecological malignancies (uterine and
ovarian), as in this case, may block the lymphatic drainage in the lesser pelvis. The
lymph flow then passes through the thoracohypogastric collaterals, overloading the
axillary and supraclavicular lymphatics.
This leads to lymphatic stasis in the breasts,
which accounts for the above-described
clinical and mammographic picture.
Fig. 154a
Fig. 154b
293
VIII Overall Strategy
296
VIII Overall Strategy
Perception of pathological lesions in the
breast can be difficult, especially perception
of stellate tumors. Superior image quality,
optimal viewing conditions, and a systematic viewing technique are prerequisites for
the perception of breast abnormalities.
Analysis of the perceived lesions should
be carefully performed as outlined.1
The strategy differs according to the type
of the tumor.
• Circular/oval tumors: there is usually no
perception problem. Careful analysis of
the mammograms and frequent use of
ancillary methods such as ultrasound and
percutaneous needle biopsy can often
make surgical biopsy unnecessary. The
most frequent examples of this are cysts
and fibroadenomas.
• Stellate lesions: the majority of breast
carcinomas present as stellate tumors.
Once found, 93 % of stellate tumors will
represent an invasive carcinoma; the remainder are radial scars, postsurgical
scars or, rarely, ductal carcinoma in situ.1
Radiological differential diagnosis can be
highly accurate and important for directing further management. Finding these
cancers at an early stage, when they are
small (< 10 mm) may require considerable
skill and experience in perception.
• Most calcifications in the breast represent
benign processes. Since only 20 % of consecutively biopsied clusters of calcifications represent malignant disease,2,3 detailed mammographic analysis of the
calcifications and frequent use of stereotactic needle biopsy will help to avoid
most unnecessary surgical biopsies.
• Thickened skin syndrome presents with a
striking clinical and mammographic appearance. The underlying cause of this
syndrome can be determined through a
careful analysis of the clinical and mammographic findings.
References
297
References
Chapter 1
1.
2.
3.
4.
5.
Wellings SR, Jensen HM, Marcum RG. An atlas of
subgross pathology of the human breast with
special reference to possible precancerous lesions. J Natl Cancer Inst. 1975;55(2):231–273
Wellings SR, Wolfe JN. Correlative studies of the
histological and radiographic appearance of the
breast parenchyma. Radiology. 1978;129(2):
299–306
Wellings SR. Development of human breast cancer. Adv Cancer Res. 1980;31:287–314
Azzopardi JG. Problems in Breast Pathology. Philadelphia: Saunders; 1980
Tabár L, Tot T, Dean PB. Breast Cancer: Early
Detection with Mammography. Casting Type
Calcifications: Sign of a Subtype with Deceptive
Features. Stuttgart: Thieme; 2007
Chapter 4
1.
2.
3.
Tabár L, Dean PB, Péntek Z. Galactography: the
diagnostic procedure of choice for nipple discharge. Radiology. 1983; 149(1):31-8
Sickles EA, Klein DL, Goodson WH 3 rd, Hunt TK.
Mammography after needle aspiration of palpable breast masses. Am J Surg. 1983; 145(3):395-7
Rosen PP. Rosen's Breast Pathology. Philadelphia:
Lippincott Williams & Wilkins; 2008
Chapter 5
1.
2.
3.
Tabár L, Tot T, Dean PB. Breast Cancer: Early
Detection with Mammography. Casting Type
Calcifications: Sign of a Subtype with Deceptive
Features. Stuttgart: Georg Thieme Verlag; 2007
Frouge C, Tristant H, Guinebretière JM, Meunier
M, Contesso G, Di Paola R, Bléry M. Mammographic lesions suggestive of radial scars: microscopic findings in 40 cases. Radiology. 1995;
195(3):623-5
Haagensen CD, Lane N, Lattes R. Neoplastic proliferation of the epithelium of the mammary
lobules: adenosis, lobular neoplasia, and small
cell carcinoma. Surg Clin North Am. 1972;
52(2):497-524
4.
Fenoglio C, Lattes R: Sclerosing papillary proliferation in the female breast. A benign lesion
often mistaken for carcinoma. Cancer. 1974;
33(3):691-700
5. Hamperl H. Strahlige Narben und obliterierende
Mastopathie [Radial Scars (Scarring) and Obliterating Mastopathy] [Article in German]. Virchows Arch A Pathol Anat Histol. 1975; 369(1):5568
6. Egger H, Weishaar J, Hamperl H. ‘Sterne’ im
Mammogram: Karzinome und ‘strahlige Narben’
[Stars in mammography-cancers and radial
scars] [Article in German]. Geburtshilfe Frauenheilkd. 1976; 36(7):547-53
7. Fisher ER, Palekar AS, Kotwal N, Lipana N. A nonencapsulated sclerosing lesion of the breast. Am J
Clin Pathol. 1979; 71(3):240-6
8. Azzopardi JG. Problems in breast pathology. Philadelphia: Saunders; 1980
9. Rickert RR, Kalisher L, Hutter RV. Indurative
mastopathy: a benign sclerosing lesion of breast
with elastosis which may simulate carcinoma.
Cancer. 1981; 47(3):561-71
10. Manfrin E, Remo A, Falsirollo F, Reghellin D,
Bonetti F. Risk of neoplastic transformation in
asymptomatic radial scar. Analysis of 117 cases.
Breast Cancer Res Treat. 2008 Feb;107(3):371-7
11. Tabár L, Tot T, Dean PB. Breast Cancer: The Art
and Science of Early Detection with Mammography. Perception, Interpretation, Histopathologic Correlation. Stuttgart: Georg Thieme Verlag; 2005
3.
4.
5.
6.
7.
Chapter 7
1.
2.
American College of Radiology (ACR). Breast
Imaging Reporting and Data System Atlas (BIRADS® Atlas). Reston, VA: © American College
of Radiology; 2003
Tabár L, Tot T, Dean PB. Breast Cancer: Early
Detection with Mammography. Casting Type
Calcifications: Sign of a Subtype with Deceptive
Features. Stuttgart: Georg Thieme Verlag; 2007
Molnár Z, Keller G. Kollaterale Lymphbahnen der
Thoraxwand bei tumoröser Blockade im kleinen
Becken [Collateral lymph vessels of the thoracic
wall in tumorous blockage of the small pelvis]
[Article in German]. Fortschr Geb Rontgenstr
Nuklearmed. 1969 Dec;111(6):854-6
Chapter 8
1.
Chapter 6
1.
Tabár L, Tot T, Dean PB. Breast Cancer: Early
Detection with Mammography. Crushed Stonelike Calcifications: The Most Frequent Malignant
Type. Stuttgart: Georg Thieme Verlag; 2008
Paget J. On diseases of the mammary areola preceding cancer of the mammary gland. St Bartholomew Hosp Rep 1874; 10:87-89
Hoeffken W, Lányi M. Erkrankungen der
Brustdrüse. In: Schinz ER, ed.: Lehrbuch der
Röntgendiagnostik, Band II, Teil 2. Stuttgart:
Thieme; P. 969-1041, 1981
Sickles EA, Abele JS. Milk of calcium within tiny
benign
breast
cysts.
Radiology.
1981;
141(3):655-8
Frouge C, Guinebretière JM, Juras J, Fertil B, Benali H, Contesso G, Di Paola R, Bléry M. Polyhedral microcalcifications on mammograms: prevalence and morphometric analysis. AJR Am J
Roentgenol. 1996; 167(3):621-4
2.
3.
Tabár L, Tot T, Dean PB. Breast Cancer: The Art
and Science of Early Detection with Mammography. Perception, Interpretation, Histopathologic Correlation. Stuttgart: Georg Thieme Verlag; 2005, p. 197
Citoler P. Microcalcifications of the breast. In:
Grundmann B, editor. Early diagnosis of breast
cancer. New York (NY): G. Fischer; 1978, P. 11318
Egan RL, McSweeney MB, Sewell CW. Intramammary calcifications without an associated mass
in benign and malignant disease. Radiology.
1980; 137:1-7
298
VIII Overall Strategy
Further Reading
Ahmed A. Atlas of the Ultrastructure of Human
Breast Diseases. Edinburgh & New York: Churchill Livingstone; 1978
Barth V. Diagnosis of Breast Diseases. Stuttgart:
Thieme; 2011
Bassett LW, Mahoney M, Apple S, D’Orsi C. Breast
Imaging. Philadelphia: Saunders; 2010
Berg WA, Birdwell RL, Gombos E, et al. Diagnostic
Imaging: Breast. Salt Lake City: Amirsys; 2006
Bick U, Diekmann F. Digital Mammography. Berlin:
Springer; 2011
Birdwell RL (Editor). Breast Imaging. Radiol Clin
North Am 2010; 48(5)
Birdwell RL, Morris EA, Wang S-C. Pocket Radiologist-Breast: Top 100 Diagnoses. Philadelphia: WB
Saunders; 2003
Cardenosa G. Breast Imaging Companion. Baltimore:
Lippincott Williams & Wilkins; 2007
Dronkers DJ, Hendriks JHCL, Holland R, Rosenbusch
G. The Practice of Mammography: Pathology,
Technique, Interpretation, Adjunct Modalities.
New York: Thieme Medical Publishers; 2002
Duffy SW, Hill C, Estève J. Quantitative Methods for
the Evaluation of Cancer Screening. New York:
Oxford University Press; 2001
Egan RL. Mammography. Springfield: Thomas; 1964
Feig SA. Auditing and benchmarks in screening and
diagnostic mammography. Radiol Clin North
Am. 2007; 45(5):791–800
Feig SA. Screening strategy for breast cancer. Semin
Breast Dis. 2003;6(4):161–172
Fischer U. Mammography Casebook. Stuttgart:
Thieme; 2006
Gallager HS. Early Breast Cancer: Detection and
Treatment. New York: John Wiley & Sons; 1975
Gamagami P. Atlas of Mammography: New Early
Signs in Breast Cancer. Oxford: Blackwell Science; 1996
Gershon-Cohen J. Atlas of Mammography. Berlin:
Springer; 1970
Gold RH, Bassett LW. Mammography, Thermography
& Ultrasound in Breast Cancer Detection. Saint
Louis: Harcourt Health Sciences; 1982
Hashimoto B. Practical Digital Mammography. New
York: Thieme; 2007
Hendriks JHCL, Holland R, Rijken, H. MammoTrainer:
Interactive Training for Breast Cancer Screening
Mammography. Berlin: Springer; 2004
Heywang-Köbrunner SH, Dershaw DD, Schreer I. Diagnostic Breast Imaging: Mammography, Sonography, Magnetic Resonance Imaging and Interventional Procedures. New York: Thieme Medical Publishers; 200 l
Hoeffken W, Lanyi M. Mammography. Philadelphia:
Saunders; 1977
Homer MJ. Mammographic Interpretation: A Practical Approach. New York: McGraw-Hill; 1996
Hughes LE, Mansel RE, Webster DJT. Benign Disorders
and Diseases of the Breast. Concepts and Clinical
Management. London: Saunders; 2000
Ikeda DM. Breast Imaging: The Requisites. St. Louis:
Mosby; 2010
Ingleby H, Gershon-Cohen J. Comparative Anatomy,
Pathology and Roentgenology of the Breast. Philadelphia: University of Pennsylvania Press; 1960
Kopans DB. Breast Imaging. Baltimore: Lippincott
Williams & Wilkins; 2006
Lanyi M. Diagnosis and Differential Diagnosis of
Breast Calcifications. Berlin: Springer; 1986
Lanyi M. Mammography: Diagnosis and Pathological
Analysis. Berlin: Springer; 2003
Leborgne RA. The Breast in Roentgen Diagnosis.
Montevideo: Impresora Uruguaya; 1953
Lee L, Stickland V, Wilson R. Fundamentals of Mammography. Saint Louis: Harcourt Health Sciences; 2002
Linell F, Ljungberg O, Andersson I. Breast Carcinoma.
Aspects of Early Stages, Progression and Related
Problems. Copenhagen: Munksgaard; 1980
Logan-Young WW, Yanes-Hoffman N. Breast Cancer:
A Practical Guide to Diagnosis. New York: Mount
Hope Publishing; 1995
Martin JE. Atlas of Mammography: Histologic &
Mammographic Correlations. Philadelphia: Lippincott Williams & Wilkins; 1982
Michell MJ (ed). Breast Cancer. Cambridge: Cambridge University Press; 2010
de Paredes ES. Atlas of Mammography. Baltimore:
Lippincott Williams & Wilkins; 2007
Parker SH, Jobe WE. Percutaneous Breast Biopsy.
Philadelphia: Lippincott Williams & Wilkins;
1993
Pisano ED, Yaffe MJ, Kuzmiak CM. Digital Mammography. Baltimore: Lippincott Williams & Wilkins;
2003
Potchen J, Sierra A, Azavedo E, Svane G, Potchen EJ.
Screening Mammography: Breast Cancer Diagnosis in Asymptomatic Women. Saint Louis:
Mosby; 1992
Rosen PP. Rosen’s Breast Pathology. Philadelphia:
Lippincott-Raven; 1997.
Rubin E, Simpson JF. Breast Specimen Radiography.
Philadelphia: Lippincott Williams & Wilkins;
1997
Salamon A. Beiträge zur Pathologie und Klinik der
Mammakarzinome. Arch Klin Chir. 1913;101:
573–668
Shapiro S, Venet W, Strax P, Venet L. Periodic Screening for Breast Cancer. Baltimore: The Johns Hopkins University Press; 1988
Silverstein MJ, Recht A, Lagios MD (eds). Ductal Carcinoma In Situ of the Breast. Baltimore: Lippincott Williams & Wilkins; 2002
Stavros AT, Rapp CL, Parker SH. Breast Ultrasound.
Philadelphia: Lippincott Williams & Wilkins;
2003
Strax P. Early Detection: Breast Cancer is Curable.
New York: Harper and Row; 1974
Tucker AK, Ng YY. Textbook of Mammography. Philadelphia: EIsevier; 2001
Vainio H, Bianchini F. Breast Cancer Screening. Lyon:
IARC Press; 2002
Wolfe JN. Mammography. Springfield: Thomas; 1967
299
Index
Page numbers in italics refer to illustrations
A
abscess 18, 19, 68–69, 76–77, 291
adenosis 2, 3, 124
development of 3
sclerosing 3, 190–197, 201
calcifications
3, 190–197, 201, 239, 240,
255–259
arterial calcifications 34, 142, 242, 265
axillary lymph node
enlarged 291, 292–293
metastases 145–146, 181, 213, 237, 291, 292
obstruction 290, 291, 292
B
black star 102–103, 103
breast
anatomy 2–3
metastases to 19
C
calcifications 16, 104, 170–171, 239, 296
arterial 34, 142, 242, 265
carcinoma 156–164, 169
ductal carcinoma in situ (DCIS) 169, 173–176,
179, 184–186, 188–189, 198–220, 228–238
infiltrating/invasive
177, 180–182, 184,
203–207, 213–215, 238
papillary 221–227, 277
within fibroadenoma 286
casting-type 169, 170, 172, 209–212, 216–217,
220, 237
dotted 170, 184–185, 213–215
fragmented
170, 177–185, 198–199, 208,
213–215, 218–219, 238
crushed stone-like/pleomorphic
158, 169,
170–171, 172–176, 188–189, 198–199, 220,
228–237, 242, 282–285
cysts 276, 277
oil cyst 275, 279–280
density 171
distribution 170, 239
ducts 170, 172, 239
eggshell-like 24, 175, 242, 275–280, 286
fat necrosis and 21
liponecrosis macrocystica calcificans 24
liponecrosis microcystica calcificans 24
traumatic fat necrosis 118
fibroadenoma 130, 151, 238, 242, 278, 281–285
fibrocystic change and 3, 239, 240, 241, 243–246,
254, 255–263, 269
foreign body granuloma 123
form of 170–171, 239
hemangioma 242, 287
cavernous 47
hematoma 220, 272, 274–276, 280
involutional-type 242, 249–250, 264, 280
location 170, 239
microcalcifications 38, 47, 158, 163–164, 173, 175,
188–189, 198, 209–210, 247–248, 253–259, 264,
282
miscellaneous-type 170
number of 171
papilloma 38, 51, 239, 273
juvenile papillomatosis 85
multiple 239, 270–271
phyllodes tumor 50
powdery/cotton ball/psammoma-body-like 164,
169, 171, 172, 190–197, 200–207, 228–236,
239, 240, 255–259
radial scar and 118–121
sclerosing adenosis 190–197, 201, 239, 240,
255–259
sebaceous gland 242, 266–267
secretory-disease/plasma cell mastitis-type 239,
242, 251–252, 265–268
size 171
skipping stone-like 170, 177, 221–227, 239, 240
teacup-like 239, 240, 244–246
terminal ductal lobular units (TDLUs) 170, 172,
239–240, 239
warts 242, 288
calcium oxalate crystals 240, 247–248, 253–254,
260–263
capsule 18, 21–25
carcinoma 18–19, 75, 156–164, 169
cribriform 156–164, 213, 221–227
ductal 54, 60–63, 75, 213–215
ductal carcinoma in situ (DCIS) 2, 17, 64–65,
169, 172–176, 179, 184–185, 188–189,
198–220, 228–238
infiltrating/invasive
17, 89–93, 98, 101,
102–103, 106–109, 124–146, 177–178,
180–182, 184–185, 203–207, 213–216, 238
micropapillary 177–178
inflammatory 291
intracystic 18
lobular, invasive 102, 103, 151–155
medullary 70–73
mucinous 18, 19, 53–54, 58–59, 80–81
ovarian 293
papillary 18, 75, 89–93, 277
micropapillary 213, 221–227
tubular 116–117
within fibroadenoma 18, 216–217, 286
cavernous hemangioma 18, 19, 47–48
comet tail sign 60, 89–90, 286
contour retraction 12–14, 127, 130–131, 145
core biopsy 20, 116, 152
see also needle biopsy
cystosarcoma phyllodes see phyllodes tumor
cysts 2, 18–19, 37, 41–44, 122, 190–192
calcifications 242, 275–276, 277, 279–280
medullary carcinoma in 70–73
multiloculated 3, 17
oil 18, 19, 23–24, 31, 104, 242, 275, 277, 279–280
papillary cancer in 99–100
sebaceous 18, 19, 46, 57
tension 17
D
desmoplastic reaction 133, 199
duct 2, 3, 241
calcifications 170, 172, 239, 241
extralobular terminal 2
intralobular terminal 2
ductal carcinoma in situ (DCIS) see carcinoma
ductectasia 2
E
eczema 78, 220
epitheliosis 2
F
fat necrosis 21
liponecrosis macrocystica calcificans 24
liponecrosis microcystica calcificans 24
traumatic 102, 104, 118–119, 122
fibroadenolipoma 18, 19, 25, 26, 28
fibroadenoma 2, 18–19, 32–36, 37, 55–56, 86–88, 98,
277
calcified 130, 151, 238, 242, 278, 281–285
carcinoma within 18, 216–217, 286
giant 18, 19, 45
hyalinized 130, 281, 286
sclerotic 282
fibrocystic change 2, 172, 229, 241
calcifications 3, 239, 240, 241, 243–246, 254,
255–263, 269
development 3
fine needle aspiration biopsy see needle biopsy
foreign body granuloma 123
G
galactocele 18, 19, 26–27, 28
galactography 51, 52
giant fibroadenoma 18, 19, 45
granuloma, foreign body 123
H
halo sign 18, 25, 32, 36–37, 43–45, 50, 70, 83, 86–87,
287
hand-held viewer 6, 6
hemangioma 19
calcifications 47, 242, 287
cavernous 18, 19, 47–48
hematoma 18, 19, 26, 28, 30–31, 83
calcified 220, 272, 274–276, 280
I
image quality 16
intramammary lymph node 18, 19, 26, 28–29, 84,
265
J
juvenile papillomatosis 85
L
lesion classification 16
leukemia 19, 78, 82
lipoma 18, 19, 21–22
liponecrosis macrocystica calcificans 24
liponecrosis microcystica calcificans 24
liposarcoma, myxoid 94–97
lobe 2, 2
lobule 2
lymph nodes 19
enlarged 19, 76, 78, 82, 291, 292–293
intramammary 18, 19, 26, 28–29, 84, 265
metastases 180–181
axillary lymph node 145–146, 181, 213, 237,
291, 292
obstruction 290, 291, 292
lymphedema 290, 292
causes 291
lymphoma 19, 66, 78
M
magnetic resonance imaging (MRI) 222–223
malignant melanoma metastases 74
mammograms
image quality 16
viewing of 6–14, 16
masking 6
horizontal 6, 6, 7
oblique 6, 8, 9
mastitis 291
plasma cell 118
calcifications 239, 242, 251–252, 265–268
medullary carcinoma 70–73
metastases
lymph node 180–181
axillary 145–146, 181, 213, 237, 291, 292
ovarian carcinoma 293
300
VIII Overall Strategy
to the breast 19
malignant melanoma 74
microhematoma, calcified 272, 274
mucinous carcinoma 18, 19, 53–54, 58–59, 80–81
myxoid liposarcoma 94–97
N
necrosis 172–174, 176, 179, 182, 184, 199, 208–213,
218–219
see also fat necrosis
needle biopsy 20, 27, 34, 41, 55, 68, 70, 83, 94–95,
104, 200–202, 229, 287
ultrasound-guided
32, 55, 68, 76, 98, 116,
152–154
neoangiogenesis 224
neoductgenesis 2, 102–104, 163, 165–167, 179,
182–183, 208–210, 213–215, 218–219
nipple, Paget’s disease 220
nonspecific asymmetric densities 165
intracystic 99–100
papilloma 2, 18, 19
calcified 38, 51, 239, 270–271, 273
intracystic 38
intraductal 51–52, 83, 229, 232
multiple 18, 19, 51–52, 85, 239, 270–271
papillomatosis, juvenile 85
parenchymal distortion 10–11, 140
contour retraction 12–14, 127, 130–131, 145
peau d’orange 68, 76, 291, 292–293
phyllodes tumor 18, 19, 50, 67
plasma cell mastitis 118
calcifications 239, 242, 251–252, 265–268
pneumocystography 37, 44, 70, 71
psoriasis 78
R
radial scar 3, 101, 102, 104, 110–115, 118–121,
147–150
rheumatoid arthritis 19, 78, 79
O
oil cyst 18, 19, 23–24, 31, 104, 242, 277
calcified 275, 279–280
P
Paget’s disease 220
papillary carcinoma 18, 75, 89–93, 277
S
sarcoma 19
sclerosing adenosis 3, 190–197, 201
calcifications 3, 190–197, 201, 239, 240, 255–259
sclerosing duct hyperplasia see radial scar
sebaceous cyst 18, 19, 46, 57
sebaceous gland calcifications 242, 266–267
specific asymmetric densities 165
stellate lesions 11, 102, 105, 296
see also specific lesions
Swiss cheese disease 85
T
tension cyst 17
tent sign 12, 13, 127, 145
terminal duct lobular unit (TDLU) 2, 2, 3, 241
calcifications 170, 172, 239–240, 239, 241
cystic transformation 3
fibroadenomatoid change 17
thickened skin syndrome 16, 290, 291, 292–293, 296
trauma 30–31
fat necrosis 102, 104, 118–119, 122
tripolar mitosis 70, 73
U
ultrasound 18, 20, 32, 37, 38, 44, 63, 67, 89–90,
94–96, 98, 99, 103, 152–154, 190–194, 221–222,
228–229, 254
ultrasound-guided needle biopsy 32, 55, 68, 76, 98,
116, 152–154
W
warts 18, 49
calcifications 242, 288
weddelites 240, 247–248, 253–254, 260–263
white star 102, 102, 108