1.

6
Introduction to Mammography
July 14, 2015
Maria Louven Urbano-Grasparil, MD, FPCR
OUTLINE
I. Mammary Glands I. MAMMARY GLANDS
II. Breast Anatomy  Exocrine glands: enlarged and developmentally modified sweat
III. The Mammogram glands
A. Craniocaudal (CC) View  Functions:
B. Mediolateral (MLO) View o Milk production
IV. Examples of Mammograms
o Pass antibodies to the newborn (passive immunity)
A. Fatty Parenchyma
B. Minimally Scattered Fibroglandular Tissue
II. BREAST ANATOMY
C. Heterogenously Dense Fibroglandular Tissue
D. Extremely Dense Fibroglandular Tissue
V. Mammographic Abnormalities
A. Mass
B. Spiculations
C. Calcifications
1. Vascular Calcifications
2. Cluster of Microcalcifications
3. Linear Calcifications
D. Tissue Asymmetry
E. Architectural Distortion
VI. Axillary Lymphadenopathy
VII. Breast Augmentation
A. Silicone Implants
B. Saline Implants
This lecture-based trans is from 3A 2016 transcription and Brant’s Fundamentals of
Diagnostic Radiology 4th ed. Only the first 3 parts were discussed by Dra, so bahala
na kayo kung gusto niyo pang basahin yung mga succeeding parts 

Blue: Lifted from Snell 9th edition

Italicized: Brant

Breast imaging has two purposes:

1. To screen asymptomatic women for early breast cancer
2. To evaluate breast abnormalities in symptomatic patients or patients
with indeterminate screening mammograms.

Screening for Breast cancer:

 Breast cancer survival is influenced by the size of the tumor and the
lymph node status at the time of diagnosis
 Small tumors with negative axillary lymph nodes have survival rates
well above 90%

*The U.S. Preventive Services Task Force (USPSTF, 2009) withdrew

its support for mammographic screening for women in their forties and
recommended that women ages 50 to 74 years be screened biennially.

 A greater proportion of breast cancers grow faster in younger women

than in older women
 Breast cancer between the ages of 40 - 49 : 1 in 66 women or 2%
 The chance of dying from breast cancer: 0.3%
 For postmenopausal women: there is no increase in late-stage
cancers diagnosed if screening is done every 2 years instead of
annually
 The incidence of breast cancer does increase with age. A. LOBES AND LOBULES
 Experts suggest that mammographic screening should STOP when:  15-25 lobes that radiate around nipple
 life expectancy is ess than 5 to 7 years  Each lobe consists of 20-40 lobules
 abnormal results of screening would not be acted on because of B. GLANDULAR TISSUE
age or comorbid conditions 1. ALVEOLI
 Factors known to increase a woman’s risk include the following:  Grape-like clusters of cells where milk is produced
 A personal history of breast or ovarian cancer 2. DUCTULES
 a carrier of the BRCA1 or BRCA2 genetic mutation (estimated risk  Branch-like tubules from the lobules to lactiferous ducts
of up to 80% development of breast cancer by age 70. 3. LACTIFEROUS DUCTS
 Having a mother, sister, or daughter with breast cancer 4. LACTIFEROUS SINUS
 Atypical ductal hyperplasia (ADH) or lobular neoplasia diagnosed C. SUSPENSORY LIGAMENTS OF COOPER
on a previous breast biopsy  For support of parenchyma and glands
 A history of chest irradiation received between the ages of 10 and  Fibrous bands that attach the breast to the chest wall
30 years.  Linear structures extending from pectoralis muscle
 1 in ever 8 women will develop the disease during her lifetime  In younger females, these makes the breast firm and perky
 Statistics: D. BLOOD VESSELS
 over 50% of cancers will be minimal  Perforating branches of the internal thoracic artery
- minimal cancers are defined as those that are noninvasive or  Intercostal arteries
invasive, but less than 1 cm in size with negative nodes.
 Axillary artery via lateral thoracic and thoracoacromial branches
 9% to 16% of cancers are not visualized mammographically
- discovered on physical examination  Veins corresponds to the arteries
- minimum size of breast cancers that can be felt on E. NERVES
PE: averages between 1.5 and 2 cm F. LYMPH NODES
 A negative mammogram should not deter further diagnostic G. FAT
evaluation of a clinically palpable mass
 increased susceptibility to breast cancer among women exposed to
high doses of radiation (1 to 20 Gy)

Rusty and Tam 1 of 9

RADIOLOGY: INTRODUCTION TO MAMMOGRAPHY 1.6

III. THE MAMMOGRAM

 Orientation
o Outer at the top
o Inner at the bottom
 Densities
o Radiopaque or white
 Fibroglandular breast tissue
o Radiolucent
 Retromammary fat
 Fat at the anterior aspect of the breast (*)
 Nipple
o Nipple is always at the midline ("in profile")
o Normally, a marker (usu. small stainless steel marker or clip) is
placed on the nipple; seen as a white spot
 An alternative method of assuring appropriate visualization of
posterior tissues:
- To measure the distance from the nipple to the edge of the film
through the central axis of the breast; this distance should be
within 1 cm of the length of the posterior nipple line as seen on
the MLO view

Craniocaudal (CC) view. An imaginary line (dashed white line) is

drawn from the center of one nipple to the center of the other nipple.
Above the line are the outer quadrants; below the line are the inner
quadrants. Radiopaque breast tissue (BT); radiolucent retromammary
fat (yellow circle); radiolucent fat anterior to breast tissue (asterisk).

B. MEDIOLATERAL (MLO) VIEW

 Depicts the greatest amount of breast tissue
 Most useful view in mammography
The mammogram and its main parts.
 The source hits the medial aspect of the breast and goes through the
lateral side (hence the term mediolateral view)
 Nipple should be "in profile" (at the midline)
 An imaginary line divides the breast into upper and lower halves
 Early detection is very important
 Pectoralis must be seen as well as a portion of the axilla
o Due to incidence of breast cancer
 The machine, not the patient, will rotate
 Screening by mammography starts at 40 years old
o A diagonal view of the breast will be obtained
o Earlier (30 years old) if with family history of breast cancer
o The angle is generally between 40 ° and 60 ° from the horizontal.
o Small masses are not palpable
o It will image a portion of the:
 In young women, mammary glands are very dense
 Axilla
o Opaque on mammography may mask cancer
 With round densities (representing lymph nodes) if there
o If less than 40 years old, do ultrasound instead
are masses
 Breasts
 Nipples
A. CRANIOCAUDAL (CC) VIEW
 Densities (same with that of CC view)
 Direction of radiation is from cranial to caudal o Radiopaque: breast tissue
 Breasts are pressed downward o Radiolucent: fat
o Breast tissue is brought as close as possible to the detector to  Portion of the axilla: axillary fat
get an optimal image
o Ideal compression: 4 cm thickness
 Taken with patient upright
 Must be relaxed (breast may "pull up" if tense)
 Glandular tissue is compressed

RUSTY AND TAM 2 of 9

RADIOLOGY: INTRODUCTION TO MAMMOGRAPHY 1.6

The order of views is up to the radiologist. Doc prefers to look at the

MLO view before the CC view.
Mediolateral (MLO) view. Right upper (RU); left upper (LU); right
lower (RL); left lower (LL). Portion of the axilla (A, green); pectoralis
major (P, red); radiopaque breast tissue (BT); radiolucent fat (F);
Cooper's ligament (CL, blue).

Normal mammogram. Pectoralis muscle (1); benign lymph node (2);

adipose tissue (3); ducts and glandular tissue (4)

 To localize the lesion, get 2 views (MLO and CC)

IV. EXAMPLES OF MAMMOGRAMS

A. FATTY PARENCHYMA
 Homogenous
 Fat is radiopaque (very gray) on X-ray
 Almost devoid of glands
 Very minimal streaky, linear densities (yellow arrows)
o Possibly residual breast tissue or ligaments
 If lesions are present, it would be very radiopaque (super white, like
a "light in a tunnel")
 Fatty parenchyma is usually seen in the elderly
o Mammary glands have already involuted
o Common in >60 years old

RUSTY AND TAM 3 of 9

RADIOLOGY: INTRODUCTION TO MAMMOGRAPHY 1.6

D. EXTREMELY DENSE FIBROGLANDULAR TISSUE

 Extremely dense: mostly breast tissue; almost devoid of fat
 If you would notice, extremely dense breasts are usually small; fatty
breasts are larger
 Usually seen in patients <35 years old
o Common among teenagers, 20s, early 30s
 Glands are still present and functional
 This is why mammography is ideally requested for patients >40
years old

o Mammograms of younger patients, e.g. 21 years old, would

show lots of radiopacities because of the dense breast tissue
o If there is any lesion/abnormality present, which would also
be white or radiopaque, it would be obscured by the breast
tissues

 According to the guidelines:

o If there is very high suspicion for breast CA (even for a young

patient), perhaps because of family history, request for a
mammogram provided the patient is ≥25 years old (in the States;
in the Philippines, 30 years old)
o Otherwise, it’s better to do an ultrasound

Extremely dense fibroglandular tissue.

B. MINIMALLY SCATTERED FIBROGLANDULAR TISSUE
 Parenchyma (yellow circle) is <25% of breast
 Axillary nodes (red arrow)
o Radiopaque with central lucency V. MAMMOGRAPHIC ABNORMALITIES
1. Masses
2. Spiculated densities
3. Calcifications: macro- or micro-; vascular
4. Tissue asymmetry: global or focal
5. Architectural distortion

A. MASS
 In mammography, do NOT use the term "nodule" even if it is <3 cm
 When describing masses, include:

o Borders (Well-defined? Smooth? Irregular?)

 Cyst: smooth walls, benign
 Mass: irregular borders
 If unsure whether a lesion is cystic or solid, do an
ultrasound

Three-dimensional measurement (L x AP x T) of the mass is done for

purposes of chemotherapy.

C. HETEROGENOUSLY DENSE FIBROGLANDULAR TISSUE

 Breast tissue: radiopaque or densely white
o Can possibly obscure masses request for an ultrasound

Heterogenously dense fibroglandular tissue.

RUSTY AND TAM 4 of 9

RADIOLOGY: INTRODUCTION TO MAMMOGRAPHY 1.6

Right upper outer quadrant mass (red arrow). Minimally scattered,

very large mass measuring ~2-3 cm, well-defined (generally has a Mass in the right upper inner quadrant (red)
smooth wall), lobulated, located in the right upper outer quadrant.
 CC view: appears smooth
 MLO view: appears to have shaggy/irregular borders (not what the
radiologist wants to see)
 Request for spot compression view of right upper inner quadrant

Mass in the left lower inner quadrant (green)

 Mass appears like a cyst; has very smooth borders

 Even if the mass is lobulated (CC view), it is well-delineated and
smooth

Do ancillary views, e.g. compression magnification view, to confirm

(compression paddle also acts as a magnifying lens).

B. SPICULATIONS
 Masses with lines (spicules) that radiate from the center
 Borders are irregular
 Highly suspicious for malignancy
 Typical of cancers (RED FLAG)

Here, you can notice the presence of multiple nodularities on the Spiculation, compression magnification view.
right breast (yellow arrows) and a possible bilobed mass (red arrow)
which requires further assessment using ultrasound.

 If there are multiple "masses," do ultrasound

o If cystic: benign do not remove
o If solid:
 Fibroadenoma "no-touch" lesion
 Malignancy FNAB or excision biopsy

This is a spiculated density with architectural distortions. Nipple (pink

arrow) is retracted. There is a radiopaque band (yellow arrow)
extending from the mass into the retroareolar space, extending into the
nipple (possible involvement of the areola). HIGHLY SUGGESTIVE
OF CARCINOMA.

RUSTY AND TAM 5 of 9

RADIOLOGY: INTRODUCTION TO MAMMOGRAPHY 1.6

 Clustered
o Calcifications assume this pattern if
they originated in the grape-like
structures (alveoli)
 Linear or branching
o Calcifications assume this pattern if
they originated in the ducts (may
indicate ductal carcinoma)
 Benign
PATTERN/ o Diffuse or widely scattered and seen
DISTRIBUTION bilaterally are usually indicative of a
benign process
o Multiple, bilateral clusters of
calcifications that appear
morphologically similar are also
generally benign
 Malignant
o Malignant calcifications usually occur
in groups or clusters within a small
volume of tissue.
 Circular and micro
o Usually benign
MORPHOLOGY  Irregular and amorphous or
pleomorphic
o Usually malignant

1. VASCULAR CALCIFICATIONS
 Common in the elderly (eg. arteriosclerosis)
Mass with irregular borders and spiculations (red); macrocalcification  Runs along the breast tissue
(yellow) that is coarse and benign; vessel (blue).  No traction
 Benign; become linear and regular
 The more ill-defined the border of the mass, the more likely that it is
malignant  do biopsy

C. CALCIFICATIONS
 May be physiologic or pathologic
 Calcifications are a frequent finding on mammographic examinations.
 In majority of cases, calcifications will be benign and their origin, as
such, will be easily identifiable.
 Optimal mammography is important when calcifications are being
studied. The film exposure must be appropriate
o Slight over penetration of film is optimal for detection of
calcifications.

ACCORDING TO
 Benign Calcifications
o Calcification with lucent center should
not cause concern
o Calcifications that layer into a curvilinear
or linear shape on 90 degress later films,
yet appear as smudged clusters on CC
views, are also representative of a
benign process.
 Fibroadenoma
o Calcify in various patterns.
o Sometimes the calcifications are
indeterminate, but the classic
calcifications associated with an
atrophic fibroadenoma, are large,
FORM coarse and irregular in shape.
 Secretory Disease
o Smooth, long, thick linear calcifications
that radiate toward the nipple in a
generally orderly pattern.
o Located in ectatic ducts.
 Malignant Calcifications
o Vary in shape and size
o Jagged, irregular and are often
branching
 Indeterminate Calcifications
o Account for the majority of
mammographically generated biopsies
of calcifications
o Associated with fibrocystic change.
 Macrocalcifications
o >1 mm
o More benign
2. CLUSTER OF MICROCALFICATIONS
 Microcalcifications
o <1 mm  Clustered, pleomorphic microcalcifications, with or without an
o RED FLAG associated soft tissue mass, are a primary mammographic sign of
 Benign Calcifications breast cancer.
SIZE o Often larger  This is one finding that we do not want to see
o When benign disease produces  ≥5 microcalcifications (<1 mm) in a 1 cm2 area
clusters of calcification, the size of o If 1-4 microcalcifications  more benign
these calcification is usually similar. o ≥5 microcalcifications  check again
 Malignant Calcifications  Although we cannot determine the type of carcinoma from this
o Generally less than 0.5 mm in size. abnormality, we can guide the surgeon if the lesion is highly
o Frequently referred to as suggestive of carcinoma (based on grading)
microcalcifications
 Calcifications associated with malignancy
are generally quite numerous.
NUMBER  The greater the number of calcifications,
the more likely they are associated with
malignant disease.

RUSTY AND TAM 6 of 9

RADIOLOGY: INTRODUCTION TO MAMMOGRAPHY 1.6

D. TISSUE ASYMMETRY
 Almost symmetrical calcifications on both breasts: more benign
(e.g. mastitis – diffuse and bilateral)

Symmetric calcifications of mastitis. The calcifications are

symmetrical and on the same area, hence, carcinoma is unlikely.
Correlate with patient clinically (has fever, breast tenderness, etc.). A
biopsy might be suggested because it might be an overt case of CA
Microcalcifications. >5 microcalcifications in 1 cm2, clumped, which superimposes lupus mastitis. However, according to Doc, she
pleomorphic cluster of microcalcification. if present, do biopsy/excision. would suggest first to give treatment for this patient then follow-up after
1 week; most likely, this will resolve. If not, it is likely CA.

 Focal calcifications: may be malignant

o There is a small chance for CA to manifest as bilateral masses

Focal or global asymmetry There is a lesion on the right breast with

irregular margins and spiculations on the posterior aspect.
Parenchyma is fatty and minimally scattered.

Cluster of pleomorphic microcalcifications, magnified. The

surgeon will usually proceed with an excision upon seeing this.

3. LINEAR CALCIFICATIONS
 Intraductal calcifications
 Focal, linear, branching calcifications (white arrow)  biopsy (might
be ductal carcinoma)

Focal asymmetry. The area in the right upper breast appears denser
than the corresponding area on the left. This could still be a breast
tissue – dense (could be a young patient). Request for ultrasound
(targeted US on the right breast) to confirm,especially if it is a palpable
mass.

Linear calcification. This most likely suggests a ductal carcinoma in

situ (non-contrast study).

RUSTY AND TAM 7 of 9

RADIOLOGY: INTRODUCTION TO MAMMOGRAPHY 1.6

Focal asymmetry. Density with spiculated border on the left.

Architectural distortion in a breast 50 months post-radiation (left
Gynecomastia (G, black arrow).
image). Fibrous scar (arrow) pulls the surrounding breast parenchyma
toward itself.

Global asymmetry. Right and left are markedly unequal with the
lesion entirely on one side. This could either be a mass or just breast
tissue; to confirm, request for ultrasound. There is increased glandular
tissue on the left breast. Parenchyma is minimally scattered.

Spiculated density (black arrow). A mass, especially if neoplastic,

tends to fibrose. It is aggressive. It wants everything, pulling tissues
and taking all of the blood supply for itself. If it increases in size after 6
months or 1 year, it should be excised.

CLUES IF THE LESION IS A BREAST CA

 Mass with irregular or spiculated margins
 Cluster of pleomorphic microcalcifications
 Linear, branching forms of asymmetries
 Architectural distortions

VI. AXILLARY LYMPHADENOPATHY

 Axillary lymph nodes are frequently visualized on the MLO
mammogram.
 Normally, they are less than 2 cm in size and have lucent centers or
Asymmetric with minimally scattered parenchyma. Lesion is not mass- notches resulting from fat in the hilum. Fat infiltration of the nodes
themselves can cause lucent enlargement and replacement.
like. Macrocalcification (black arrow); lymph nodes (yellow arrows).
 If rounded, with no fatty hilum, and very dense, consider it as
Compression magnification should be done. lymphadenopathy even if it is small or not enlarged
 Fat-laden  normal
 Larger (>2 cm), no fat  biopsy
E. ARCHITECTURAL DISTORTION  In reading the mammogram, do not ignore the lymph node, especially
 Usually seen post-surgery due to scarring if there was a previous if it is easily visualized
surgery for cancer
o Healing results in fibrosis
 Alarming because it might be a sign of recurrence
 Confirmed with biopsy or MRI
 Occasionally heralded by distortion in the normal architecture of the
breast.
 Differential diagnosis includes fat necrosis related to scarring from
previous surgery and a complex sclerosing lesion, also known as
radial scar.
 On close infection, fat may be seen interspersed with fibrous
elements in the center of fat necrosis or complex scleroing lesions,
but this appearance is not specific for benignity. Similar findings can
be seen in malignant lesions.
 Biopsy is necessary for differentiation.

RUSTY AND TAM 8 of 9

RADIOLOGY: INTRODUCTION TO MAMMOGRAPHY 1.6

 Implants can be placed either anterior (prepectoral) or poster

(subpectoral) to the pectoralis muscle.
 Fibrous capsule usually develops around the implant.
 Patients having prepectoral implants are subject to greater risk of
fibrous and calcific contractures around the implant.
 Screeing mammography in the woman with implants requires the use
of at least two extra views of each breast, standard MLO and CC
views with moderate compression.
 Although some breast tissue may obscured in patients with implants,
these women, when in the appropriate age groups, deserve the same
careful screening examinations at the same intervals as patients
without implants.

A. SILICONE IMPLANTS
 If the patient has implants, make sure to indicate it in the request so
that the breasts will not be over compressed during mammography
 Recent implants
 If with infections, do not do mammography or ultrasound as there will
be nothing to see
 Implants located anterior to pectoralis muscle and posterior to the
breast tissue
 If injectable implants, request for MRI instead as alternative
o Patients with silicone bags can undergo mammogram
 Silicone is made up of water; hence the hyperdense appearance
 Patients with breast implants can still be evaluated
 Silicone is more radiopaque than saline, although neither allows
adequate visualization of immediately surrounding tissue

Large, lobulated, dense LN (red box)

Silicone implants. Breast tissue (asterisk); lymph node (red arrow).

B. SALINE IMPLANTS
 LINGUINE SIGN
o Represents layers of collapsed elastomeric shell contained in the
fibrous capsule
o Present in ruptured or collapsed implants
o Hallmark of intracapsular rupture
o If a confirmed saline implant is ruptured, there is no need for any
intervention because the body will simply absorb the saline

Small, very dense LN (green arrow).

Saline implants. Folds (blue arrow) are ruptured implants with leak;
thin breast tissue (yellow arrow).

VII. BREAST AUGMENTATION

 Various types of implants have been used in augmentation
procedures. They include silicone envelopes filled with saline or with
viscous silicone gel, as well as double-lumen implants contain an
inner core of silicone gel surrounded by outer envelope filled with
saline.

RUSTY AND TAM 9 of 9