v.32-2002

Prevention ofBreast Cancer

HEALTHCAREMONOGRAPH

SERIES ENUMBER 27

Series ENumber 27

MAMMOGRAPHIC ATLAS

Reading System of Valencia Breast Cancer Screening Programme

in Valencia Community

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


MAMMOGRAPHIC ATLAS

Reading System of Valencia BreastCancer Screening Programme

Published by:Generalitat Valenciana Autonomous Government

Health Authority

For further information please get in touch with:

Dirección General de Salud PúblicaUnidad de Prevención de Cáncer

C/ Micer Mascó, 3146010 VALENCIA, SPAIN

Telephone nº: (+34) 96 386 66 01E-mail: [email protected]

National Book Catalogue Number: V - 32 - 2002

Printed by: Gráficas Marí Montañana, s.l.Santo Cáliz, 7 • 46001 VALENCIA (Spain)

Tel. 96 391 23 04* • Fax 96 392 06 39

E-mail: [email protected]

Project 172/2000

“To structure a computerized screening mammography file for training and evaluation of the readers”

2nd edition financed by the European Commission, 2000

Copyright: 2001 Dirección General para la Salud Pública. Conselleria de Sanidad.Translation: Borgoñón. Traducciones y Textos.

MAMMOGRAPHIC ATLAS

Reading System of Valencia Breast CancerScreening Programme (VBCSP) SPAIN

EDITORS

FRANCISCO RUIZ-PERALESChief of Mammography, Departament of Radiology

University Hospital La Fe

Radiology Coordinator of the VBCSP

ISIDRO VIZCAÍNO ESTEVEChief of Mammography, Departament of Radiology

University Hospital Dr. Peset

Radiology Consultant of the VBCSP

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PRESENTATION

For some years now mammographic screening has been used in the ValenciaCommunity for the early detection of breast cancer. This is currently being madeavailable to all women from 45 to 65 years of age (in the next two years this agegroup will be extended to 69), at twenty-three Breast Cancer Screening Facilitiesworking to the recommendations of the European Community’s “Europe AgainstCancer” (EAP) programme.

This attempt to provide prevention for a wide range of the population requiresnew efforts day in, day out, in order to ensure that all the professionals involved havethe very best qualifications and commitment.

Mammographic studies form the central mainstay of breast cancer screeningprogrammes, whose final results are to be a reduction in mortality. Mammographycan only fulfil its role as a test for screening if a technical level and an excellentreading quality are ensured to allow the diagnosis of breast cancer in its early stages,thus implementing secondary prevention of this disease.

To obtain the highest standard of uniformity in reading a reading system wasimplemented and then gradually updated and established by consensus, through theteamwork of a group of readers from the Programme. The result of this process wasthe publication of the Mammographic Atlas (Valencia Breast Cancer ScreeningProgramme Reading System) which was published in 1998.

The updated edition of the Mammographic Atlas in English forms part of a projectby the European Breast Cancer Network, which was joined by the Valencia Communityin 2000. This network is characterised by cooperation between European Unioncountries and a synergetic approach to its work. The project aims to build acomputerised mammographic library to enable the training and official recognition ofmammography readers in screening programs. A CD-Rom has also been made withimages of biopsied cases to support continuing training.

Training of professionals and physical-technical quality forms part of an approachto population screening as a process in which only quality assurance in each and all ofits aspects can ensure that people are provided with a preventive option in line withthe most demanding international standards.

The Autonomous Government Health AuthoritySerafín Castellano Gómez

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INDEX OF AUTHORS

Andreo Hernandez Luis A. Hospital Virgen de los Lirios. Alcoi. Coll de la Vega, Margari-ta. Unidad de prevención de cáncer de Mama. Xativa. Gadea Boronat, Leopoldo. Unidad deprevención de cáncer de mama. Alcoi. García Redón, Teresa. Unidad de prevención de cáncer demama. Castellón I. Hernandez Jimenez, Angel. Unidad de prevención de cáncer de mama.Alicante I. Martín Diez, Félix. Hospital Lluis Alcanyis. Xátiva. Montes Avila, Manuel. HospitalGeneral de Elda. Olagüe de Ros, Ramón. Hospital General de Requena. Redondo Ibañez,Marta. Hospital General de Castellón.

CONTRIBUTORS

Abderraman, Isa Musa; Aguilar Gómez, Nieves; Agulló Baeza, Trinidad; Alberola Quintar, MaríaLuisa; Ardoy Ibáñez, Francisco; Carnero Ruiz, María; Casals El Busto, María; Cervera De Val, José;Chorda Grau, Dulce Concepción; Moscardó, Luis; Cubells Martínez, María Luisa; Erades Martínez,Daniel; Estellés Lerga, Pilar; Fernández Álvarez, Gloria; Fernández García, Pilar; Ferrando Valls,Federico; Ferriols Ballester, Amparo; Florencio Quilis, Ignacio; Fuster Selva, Mª. José; Galant He-rrero, Joaquín; Gallego Gato, Juan; García Franco, Margarita; Gil Cruz, Pedro Manuel; GómezLorente, Carlos; Jordán Balanzá, Yolanda; Laso Pablos, María Soledad; Martínez Gómez, Inmaculada;Martínez Pérez, Mª. Jesús Masip Sanchis, María José; Morcillo Tur, Enma Yolanda; Morote Muro,Virgilio Núñez De Bobadilla, José; Olmos Martínez, Mª. Teresa; Ortega Gutierrez, Concepción; OrtíTarazona, Carlos; Palmi Cabedo, Pascual; Palop Jonqueres, Carmen; Pérez Clavijo, José María;Perona Zuriaga, Isabel Piqueras Olmeda, Rosa; Sanchis Aparicio, Manuel; Vidal Ferrer, Pascual;Vidal Lluch, Juan Sebastian ; Zaragoza Cardells, Eduardo.

VBCSP COORDINATING COMMITTEEPRESIDENT:Manuel Escolano Puig. General Director of Public Health. Autonomous Government HealthAuthority.

MEMBERS:Dolores Salas Trejo. Head of the Cancer Prevention Programme.

Mª Dolores Cuevas Cuerda. Central Administration Health.

Monserrat Sánchez Lorente. Central Administration Health.

Francisco Ruiz Perales. Radiology.

Isidro Vizcaíno Esteve. Radiology.

Ignacio Aranda López. Pathology.

Vicente Torres Gil. Pathology.

Ignacio Petschen Verdaguer. Radiotherapeutic oncology.

Ana Lluch Hernández. Medical oncology.

Constantino Herranz Fernández. Medical oncology.

Carlos Vazquez Albadalejo. Surgery.

Ignacio Villaescusa Blanca. Radiological protection.

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ACKNOWLEDGEMENT

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

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CONTENTS Pages

CHAPTER I. THE MAMMOGRAPHIC REPORT ................................................ 13

CHAPTER II. CATEGORY 1. “NORMAL” ........................................................ 17

CHAPTER III. CATEGORY 2. “BENIGN” ......................................................... 23

CHAPTER IV. CATEGORY 3. “PROBABLY BENIGN” ....................................... 29

CHAPTER V. CATEGORY 4. “PROBABLY MALIGNANT”.................................. 33

CHAPTER VI. CATEGORY 5. “MALIGNANT” .................................................. 39

CHAPTER VII. MISCELLANEOUS................................................................... 43

APPENDIX I. DIAGNOSTIC PROTOCOL. ........................................................ 49

APPENDIX II. WORK SHEET ......................................................................... 57

FIGURES:

NORMAL................................................................................................ 61

BENIGN ................................................................................................. 75

PROBABLY BENIGN ............................................................................... 93

PROBABLY MALIGNANT......................................................................... 109

MALIGNANT........................................................................................... 131

MISCELLANEOUS................................................................................... 141

INDEX OF FIGURES...................................................................................... 155

INDEX OF TERMS USED............................................................................... 159

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CHAPTER I

THE MAMMOGRAPHIC REPORT

F. Ruiz Perales

The mammographic report in a screening programme is not the same as the one used in amammary pathology diagnosis facility. At mammary pathology facilities, reports tend to be presentedin form of free text, sometimes using histopathological terms, when the correlation between theradiological image and pathology is simply a subjective impression and sometimes referring to theresult of applying several techniques, frequently mammography with ultrasound, to obtain a jointreport (1-3).

In a screening programme, the aim of the mammography report is to separate cancer-free peoplefrom those with some possibility of having cancer, and at the same time to classify the second groupby their greater or lesser probability of having breast cancer.

The classifications may vary, but their aim is to make decisions allowing the final diagnosis ofcancer or no cancer to be established. The approaches involved will naturally be more aggressive thegreater the probability of suffering from cancer and more conservative the lower this probability (1).

We should be aware of the fact that there are exceptionally cancers that are not visible in themammography, even though the breasts are fatty, because these are invisible and more often becausethey are hidden deep in breasts with dense tissue, which occasionally make it difficult or impossible toidentify them by radiology. There are cancers which are palpable before they can be identified bytheir radiological signs (1, 4, 5).

Occult cancer is a real fact but does not give any authorisation to predict the existence of cancerwithout there being any radiological or clinical signs and neither should it lead to ambiguous reportswhich safeguard the person who issues them but do not assist the patient nor any of the specialistsinvolved in the diagnosis and treatment of breast cancer.

The mammography report in a screening system should be based on a data collection system thatis as objective as possible, that does not allow varied interpretations, confused descriptions and, evenless, misleading or ambivalent attitudes.

It should be simple, using a pre-established lexis, in which each of the terms to be used has beendefined, in order to do this properly, allow the collection of data in the simplest way, devoting theminimum time to writing, with a view to leaving the maximum time for reading the radiographicfilms. An attempt should be made to use a data collection system that can be easily transcribed on acomputer support (1, 6, 7).

Most screening programmes have adopted and registered a reading system, developing thisaccording to the needs that they have come up against and the resources available. When the aim isto standardise reports of different programmes, the reading protocols should be painstakinglydeveloped, applied to practice in previous tests and continuously reviewed by the readers who usethem.

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Although all reading systems have a common aim and the cancer detection rate of screeningprogrammes is what best vouches for their efficiency, they differ in the data collection methodologyand sometimes in the terms used, it proving very difficult to match readings in all screening programmes.

Some reading systems have been developed to solve a particular situation, while others proposethe adoption of a universal system, and if this objective were attained, it would undoubtedly meanbenefits for all and not only through allowing a large amount of case data to be compiled but alsobecause it would act as a reading quality control and would act as the basis for teaching interpretationof mammographies. (1, 4-7).

The purpose of this “Mammographic Atlas” is to divulge the reading system used at the ValenciaBreast Cancer Screening Programme (VBCSP) in the Valencia Community, illustrating this withimages which can be used as an example for all the physicians interested in screening programmesand above all those who are interested in film reading, for radiologists and also for the specialistsinvolved in these multidisciplinary programmes in which the terms used by each speciality shouldnecessarily be known.

The reading system is based on the suggestions published in the works by Svane and co. (8 ) in1992 and Koppans (9) in 1993, and developed at work meetings of the group of readers in theprogramme. It is published in the form of a modus operandi in Sanitary Monographs, Series Enumber 14.(4) and Series E, number 19 (5), Series E, number 25 (1) and Series E, number 27 (13).

All the terms constituting the lexis of the report system have been properly defined, not only intheir medical meaning but also as regards their meaning in the Royal Spanish Academy LanguageDictionary. We thus hope that no interpretations other than the ones described are possible (10, 11).

After accepting and defining normality, we have attempted to include in the benign and malignantcategories the pathology in which there is an almost absolute correspondence between the readingand the pathology. In these cases the use of pathology terms can be accepted. (Example: Lipoma)(13).

Women with some likelihood of having breast cancers have been classified in the probably benignand probably malignant categories, depending on whether there is a lesser o greater possibility ofsuffering from this. In these reports, as correlations between the radiological image and the pathologicalanatomy are not absolute, only the terms describing the mammographic image should be used. (Forexample: Nodule 13).

The choice of these categories has the aim of adopting different approaches for each of these. Inthe normal category, women are checked again two years later, this being the interval time of ourprogramme. The benign category, from the standpoint of the screening programme, will be reviewedafter two years, and nevertheless the pathology included in this category may require some type oftreatment by the physician or specialist (Example: Painful cyst 13).

Probably benign and probably malignant categories are the main objective of screening programmes.For patients falling into these categories there should be complementary studies, additional projections,ultrasound, short-term follow-up, in order to establish follow-up, cytological or histological studies,with a view to reaching a definitive diagnosis. An attempt is made to implement approachesproportional to the probability of suffering from cancer, with conservative procedures in the probablybenign cases and interventionist approaches in the probably malignant ones (1, 2, 4, 5, 13).

The cancers diagnosed by the clinic and radiology and which are occasionally found in screeningprogrammes for different causes which are not analysed here should be sent on to hospital breastfacilities, to proceed to their treatment. It would be desirable for all women participating in cancerscreening programmes to be asymptomatic.

The present reading system has been regularly modified according to the results obtained in theprogramme and this leads to suppose that they will continue to be modified, partly for the samereason and partly because technology is constantly moving on and these known motives and possiblysome that we do not know of now will lead the system to change to adapt continuously to the newrequirements (13).

The reading system has proved very useful over the years in which this has been used up to thepresent time, but many programmes nevertheless follow the guidelines proposed by A.C.R in theBIRADS system. The universality of the BIRADS system is the present requirement. (14, 15)

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This fact forces us to review and compare both systems and we conclude that they are compati-ble, with minimum differences which are not vital nor affect the final classification in Categories,which are the same for both systems and consequently so is the approach to be followed after theclassification. The divergences existing, in some cases nuances rather than differences, are given inAppendix I and refer to the classification of the reading data (13-15).

When reviewing the «Mammographic Atlas. Reading System of the VBCSP in the ValenciaCommunity» for a new edition, we wish to state that this was agreed by consensus at the EncounterSessions held in Valencia on November in 1997. In the update we give the corrections which havebeen jointly made since its publication. (13).

The reading system includes modifications or simply qualifications for better understanding as theobservations of those using it are analysed or as new requirements come up.

The development of Appendix I, which we are using at present as reading system, will explain thecompatibility with the BIRADS system.

We would finally like to express our thanks to all those who contributed to creating the readingsystem for the VBCSP in the Valencia Community. A list of the present readers and the ones that atsome time have worked on the programme and contributed to forming this procedure is given at the

beginning of the present reading text found below.

Bibliography

1. Generalidad Valenciana. Conselleria de Sanitat.Programa de prevención de cáncer de mama en la Comu-nidad Valenciana. Monografia Sanitaria. Serie E, Núm. 25. Valencia: Generalitat Valenciana, 1998.

2. Farmapress. Grupo Aula Médica, S.A. Screening de mama. Abstracts del I Curso Internacional de laSociedad Española de Diagnóstico por Imagen de la Mama (SEDIM). Madrid 1998.

3. Hommer MJ. Mammography Report (editorials). AJR 1984: 142; 643-644.4. Generalidad Valenciana. Conselleria de Sanitat. Programa de prevención del cáncer de mama en la Co-

munidad Valenciana. Monografía Sanitaria. Serie E. Núm. 14; Valencia: Generalitat Valenciana, 1993.5. Generalidad Valenciana. Conselleria de Sanitat. Programa de prevención del cáncer de mama en la Co-

munidad Valenciana. Monografia Sanitaria. Serie E. Núm.19; Valencia: Generalitat Valenciana, 1996.6. Homer MJ. Mammographic Interpretation. A Practical Approach. New York: Mc. Graw-Hill, 1997: 27-

33.7. American College of Radiology (ACR). Breast Imaging Reporting and Data System (BI-RADS™). (2nd edi.)

Reston (VA): ACR, 1995.8. Bassett LW. Standardized Reporting for Mammography: (BI-RADS™). The Breast Journal 1997; 3: 207-

2109. Svane G, Potchen EJ, Sierra A, Azavedo E. Stellate lesions. In: Patterson A. ed. Screening Mammography.

Breast Cancer Diagnosis in Asymptomatic Women. St. Louis: Mosby Year Book, 1993.10. Kopans DB. Standardized Mammography Reporting. Radiol. Clinics of North Amer. 1992; 30:257-264.11. Real Academia de la Lengua. Diccionario de la Lengua Española. Madrid: Espasa-Calpe. 2001.12. Diccionario de Sinónimos y Antónimos. Madrid: Espasa-Calpe. 1994.13. Generalidad Valenciana. Conselleria de Sanitat. Atlas Mamográfico. Sistema de Lectura del Programa de

Prevención de Cáncer de Mama en la Comunidad Valenciana. Monografía Sanitaria. Serie E, Número 27.Valencia: Generalitat Valenciana. 1998.

14. American College of Radiology (ACR). Breast Imaging reporting and data system (BI-RADS™). (ThirdEdition). Reston [VA]: American College of Radiology; 1998.

15. Kopans DB. Tratamiento de datos, falsos negativos y revisión del estudio de la mama. In: la mama enimagen. Madrid: Marban. 1999: 761-796.

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CHAPTER II

CATEGORY 1. “NORMAL”

Dr. R. Olagüe

IntroductionIf “normal” is the term applied to what acts as a norm or rule, the fact of the breast being a

dynamic organ subject to a wide range of histological/mammographic changes is the reason for thedifficulty in defining this as such. Changes of a proliferative nature take place in pre-menstruation,pregnancy, lactation, and during hormone replacement therapy (HRT), particularly when estrogenswith progesterone are administered continuously (1-3). Involutional physiological alterations are alsoobserved from 30 years of age and in treatment with Tamoxifen (4). The problem is further complicatedif we take into account the variability of the mammary gland’s individual response to the aforementionedchanges. As Homer points out, the breast is like a fingerprint, every single one is different (5).Nevertheless, to be pragmatic in establishing the modus operandi, we will use the term “normal” forthe breast that does not display signs of a pathological nature in mammography, considering thesesigns to be ones that form the description or mammographic reading (nodule/mass, structural alteration,calcifications, asymmetries and alterations of the skin or nipple), in the sense in which these arerespectively defined within the categories of benign, probably benign, probably malignant andmalignant, and which will be dealt with in the following chapters (6).

Although the classic patterns of mammographic reading can be reduced to three types (fatty,dense and mixed) in relation to the greater or lesser presence of fibroglandular tissue, in our readingprotocol we have only established two subcategories within the normal category:

1.1 NORMAL FATTY:This refers to a breast with a large fatty component, or scanty glandular tissue, mammographically

radiolucent, in such a way as to make it difficult to cover up nodules, alterations of densities orneodensities (Fig 1, page 63).

1.2 NORMAL DENSE: Includes any normal breast with visible parenchyma, of homogeneous, macro or micronodular,

patchy type, etc. and which can conceal nodules or alterations in density (Fig.2 a and b, pages 63and 64).

The terms used, “fatty” and “dense”, refer to the radiological density of the fat and the water, withthe same meaning as they are given in conventional radiology.

It is true that sometimes, above all in mixed patterns, with no clear predominance of the glandularor fatty component, the establishment of a subcategory is grounds for disagreement between readers.Nevertheless, on condition that the pattern assigned does not conceal nodules or alterations indensity, the discrepancy is not of great importance through not implying different action.

The introduction of subcategories within the normal breast is justified by their evident practicalimplications, since the dense breast reduces the sensitivity of the reading in the detection of breastcancer; a radiologically dense breast is more difficult to interpret, because the density can occasionally


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hide the presence of a structural disorganisation, an increase in density in respect of the surroundingstroma, or make the detection of microcalcifications difficult (7). A more thorough mammographicreading, along with a clinical examination and a mammary ultrasound, will contribute to the esta-blishment of the corresponding category and the action stemming from this (8). We should not forgetthat around 9% of operable cancers have negative mammographic reports, and one of the causes oferror is the false interpretation of the cancer as a benign lesion and the difficulty of diagnosing this indense breasts (9).

NODULES IN THE NORMAL CATEGORY01. Axillary or intramammary lymph nodes whose morphology and size lead them to be considered

as normal.Most of the lymphatic drainage of the breast is done by the axillary nodes and the rest by the

internal thoracic lymph node chain. In mammography it is common to discover one or more nodulesin the axillary tail or medium axillary line, in a topographical relationship with the pectoral musclesand which correspond to axillary lymph nodes.

These are to be considered part of the normal anatomy if they meet the following mammographiccharacteristics:

- Nodule of mixed density, moderate or low density and radiolucent centre, with well-definedcontours, round, oval or kidney-shaped, and on occasions with hilar groove (Fig. 3, page 64).

- Its greatest diameter must not be over 1.5 cm, except when there is fatty infiltration, which couldexceed this size (Fig. 4, page 65).

When there are occasionally doubts, spot projection with magnification is useful for betteridentification of the aforementioned characteristics, in particular of the radiolucent fatty hilum (10 )(Fig. 5, page 65).

The 5.4% of mammographies have intramammary lymphatic nodules. These can be isolated,multiple, unilateral or bilateral and their customary seat is the upper-outer quadrant (UOQ), and theperiphery of the glandular cone (11). The problem arises when these occasionally settle in otherquadrants. If they are not over 1 cm, in diameter, and keep the mammographic characteristicsmentioned for axillary lymph nodes, they will come under the normal category. If, on the other hand,these are nodules of under 0.5 cm, that are homogeneous, of low density and with well-definedcontours, they will form part of the benign category, and if these are over 0.5 cm and have the samecharacteristics as the previous one, they will be probably benign and require the correspondingfollow-up.

In the different evolutionary checks slight changes in size of the lymph nodes can be seen, whichare not significant if they keep the fatty hilum, are not palpated and if there is no history of malignancy(12).

The mammographic characteristics are in most cases sufficient to establish the diagnosis of theaxillary and intramammary lymph nodes, and in a very few exceptions we resort to ultrasound as acomplementary test, though these are difficult to identify in fatty breasts. The echographiccharacteristics are: hypoechoic oval nodules of under 1.5 cm maximum diameter with an echogeniccentral hilum (13).

Spherical and high density lymph nodes with increasing size must be considered as being pathological(Fig. 6, page 66). Given the non-specificity of these findings, which can correspond both to benignpathology (dermopathic lymphadenitis, collagenopathies), or malignant ones (leukaemia/lymphoma,metastasis) (Fig. 7, page 66), they should be valued within the overall context of the mammographicreading and analysis of their specific characteristics, going to form part of the probably benign orprobably malignant category, as we will later see in the corresponding section; these should alwaysbe given a biopsy, if we do not manage to clearly establish their benign nature. Badly defined marginsand infrequent microcalcifications in their interior are of course signs leading one to suspect metastaticcarcinoma.

01. Warts or lesions in the skin identified, if possible with a metal markAfter mammary inspection of the patient, it is important for the Radiology Technician (RT) to

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inform the radiologist of any lesion protruding from the skin such as warts, naevi, and neurofibromas,which can be projected in the mammographies as intramammary processes. These are seen in theform of well-defined masses of medium or low density, in at least one projection. When these arecompressed, the air is trapped around them, giving rise to a characteristic radiolucent halo whichsurrounds them (Fig. 8, page 67). If the surface is irregular, as occurs in the melanocytic naevus, theair trapped in its surface can be seen in the mammography as mixed density looking like paving. Bythe same mechanism, as will be seen in the chapter on miscellaneous items, any hygiene powders ordermal creams deposited inside can simulate suspicious microcalcifications. In this case, and in gene-ral in all the protruding dermal lesions, if these have not been routinely marked before carrying outthe mammographic projection, they can be identified with metal or barium markers, then making atangential projection (Fig. 9, page 67).

Epidermal inclusion cysts or sebaceous cysts, clinically indistinguishable, can cause a discreetswelling in the skin and tend to be located in the areolar zone or lower portions of the breast. Theseare well circumscribed nodules, with a subcutaneous seat, of medium or high density, which canchange in size and occasionally calcify (Fig. 10 a and b, page 68). When they inflame they can havebadly defined edges and be accompanied by skin oedema.

STRUCTURAL ALTERATION IN THE NORMAL CATEGORY:02. Stars produced by the superimposing of structuresPseudostars or “constructed images” are produced by the superimposing of normal fibroglandular

structures when the mammary gland is projected on a single plane. These are only appreciated in asingle mammographic projection, but one must take great care since some small-sized cancers canbehave in the same way. In the event of any doubt the mammographic projection can be repeated,changing the angle of incidence of the beam of radiation slightly, or making a focalised projectionwith compression (Fig. 11a and b, page 69) (14, 15).

CALCIFICATIONS IN THE NORMAL CATEGORY:03. Vascular calcificationsVascular mammary calcifications are a frequent finding in screening mammographies and are

correlated with ageing, meaning that these are often observed in postmenopausal women. Theysettle in the medium level of the peripheral arterioles (Mönkeberg medial calcific sclerosis), with atypical mammographic appearance in rail or double parallel line form, and do not usually involve anydiagnosis problem (16, 17) (Fig. 12, page 70). Only in the early phases of the calcification process,when the linear calcifications affect only a part of the wall of the vessel, can they be confused withmalignant type linear calcifications. Focal projection with magnification will help to establish theirvascular nature (Fig. 13, page 70).

03. Dermic calcificationsCalcification of the sebaceous glands is in relation to a chronic folliculitis. Although these are

seated in the dermis, being located in a flaccid easily compressed organ means that in the basicmammographic projections they seem to be intraparenchymatous (18). A careful reading of these ina magnified projection will nevertheless reveal the following typical characteristics:

• They can be seen in isolated or multiple groups, although it is more common to findthem disperse and in the medial zones linearly positioned at the periphery.• They are the same size as a cutaneous pore, with a polygonal shape and radiolucent centre.• They keep in a constant relation with each other, when similar projections are compared, even

though these are obtained at different times (tattoo sign) (19) (arrow in Fig. 13, and Fig. 14a and b,pages 70 and 71) (Fig.14).

Tangential projections with a metal marker will confirm the superficial location of these.Some deodorants, ointments or skin powders may leave traces that look like microcalcifications,

as will be seen later in the miscellaneous item chapter (20).


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03. Cicatricial calcifications.During the first few months after a biopsy, tumorectomy or reductive procedures it is not uncommon

to observe calcifications due mainly to dystrophic changes or fatty necrosis. These postoperativecalcifications are located in the cicatricial bed, there being clear agreement in the mammographies ifmetal surface markers are used. Of varied morphology, in general pleomorphic and initially linear,these become coarser and larger in time. These dystrophic calcifications may simulate malignancywhen they are small, irregular and grouped together.

Calcifications of surgical sutures are linear, curvilinear or knot-shaped. Magnified and tangentialprojections will help to confirm the surface location of these and their benign nature (Fig. 15, page72).

03. Microcystic CalcificationsMicrocycstic calcifications are a very common finding. These are annular calcifications (round

with radiolucent centre) between 0.5 and 5 mm in size, single or multiple and generally representmicrocysts by liponecrosis, although on other occasions their uncertain nature has been attributed tothe presence of calcified intraductal cellular debris (21). One should remember that calcifications withradiolucent centres are always benign (Fig. 16, page 72).

ASYMMETRIES IN THE NORMAL CATEGORY04. Asymmetries produced by normal parenchymaThe asymmetry produced by normal mammary parenchyma is observed in 3% of normal breasts.

It must meet the following characteristics:• Being asymptomatic and non-palpable,• Being located in the upper-outer quadrant or subareolar region (ductal asymmetry),• Being isodense in respect of the neighbouring parenchyma and containing fat inside,• Not being volumetric (need for a 3rd projection; focalised compression or standard with different

obliquity), with no structural distortion, nor defined margins, nor grouped microcalcifications. Special mention should be given to the accessory mammary tissue in the axillary extension,

which can be seen as an asymmetric density and as such can be the seat of both benign and malignantpathology (22) (Fig. 17, page 73).

04. Vascular asymmetry not associated with other signsThe detection of vascular asymmetry, either in size or distribution, in a routine screening study is

to be considered normal if the patient is asymptomatic and does not have any other mammographicanomalies. Accepting this as a normal variant, we must point out that their presence can be due toa different degree of compression when the mammographic study is made. Some of the pathologicalprocesses that cause vascular asymmetry are axillary or mediastinal tumorations which cause thedevelopment of collateral circulation through obstruction of the axillary, subclavian vein or superiorvein cava (23) (Fig. 18, page 73).

04. Asymmetry of volumeAs a variant of normality there is overall mammary asymmetry.Postoperative changes (biopsy or tumorectomy) can create a glandular defect at the site of the

excision and secondarily cause an asymmetric density of the normal tissue of the contralateral breast(Fig. 19, pag.74).

ALTERATIONS OF THE SKIN/NIPPLE IN THE NORMAL CATEGORY05. Cicatricial sequels of traumatisms, surgery or known and proven infectionIf the measures required for the nipple to be projected in profile in standard projections are not

taken, this may simulate the presence of a subareolar mass (pseudonodule) in the mammography.Though this occurs very seldom, projections with anterior compression or focalised subareolarprojections can solve the problem.

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Slight contusive type mammary traumatisms may cause subtle changes in the stroma with discretetrabecular and cutaneous thickening. If the traumatism was more severe, secondary steatonecrosismay cause cutaneous retraction (24).

Benign scars, most of these postoperative, may give rise to cutaneous or nipple retraction.Benign inflammation which may give rise to cutaneous, focal or diffuse thickening will be dealt

with in the chapter on the benign category.

Bibliography

1. Berkowitz JE, Gatewood OMB, Goldblum LE, Gayler BW. Hormonal replacement therapy: mammographicmanifestations. Radiology 1990; 174: 199-201.

2. Stomper PC, Van Voorhis BJ, Ravniker VA, Meyer JE. Mammographic changes associated withpostmenopausal hormone replacement therapy: a longitudinal study. Radiology 1990; 174: 487-490.

3. Lundstrom E, Wilczec B, Von Palffy Z, Soderqvist G, Von Schoultz B. Mammographic breast densityduring hormone replacement therapy: differences according to treatment. Am J Obstet Gynecol 1999;181: 348-352.

4. Ricciardi I, Ianniruberto A. Tamoxifen-induced regression of benign breast lesions. Obst Gynecol 1979;51: 80-84.

5. Homer MJ. Mammographic interpretation. A practical approach. New York: Mc Graw-Hill, 1977.6. Generalidad Valenciana. Conselleria de Sanitat.Programa de prevención del cáncer de mama en la Comu-

nidad Valenciana. Monografia Sanitaria. Serie E. Núm.19. Valencia: Generalitat Valenciana, 1996.7. Svane G, Potchen EJ, Sierra A, Azavedo E. Stellate lesions. En: Patterson A. ed. Screening Mammography.

Breast Cancer Diagnosis in Asymptomatic Women. St. Louis Mo: Mosby Year Book, 1993.8. Kolb TM, Lichy J, Newhouse JH. Occult cancer in women with dense breasts: detection with screening

US- diagnostic yield and tumor characteristics. Radiology 1998; 207: 191-199.9. Cahill CL, Boulter PS, Gibbs NM, Price JL. Features of mammographically negative breast tumors. Br.

J.Surg. 1981, 68 (12): 882-884.10. Egan RL, Mc Sweeney MB. Intrammamary lymph nodes. Cancer 1983; 51:1830-1842.11. Stomper PC, Leibowwich S, Meyer JE. The prevalence and distribution of well-circumscribed nodules on

screening mammography analysis of 1500 mammograms. Breast Dis. 1991; 4:197-203.12. Lee CH, Giurescu ME, Philpotts LE, Horvath LI, Tocino I. Clinical importance of unilaterally enlarging

lymph nodes on otherwise normal mammograms. Radiology 1997; 203: 329-334.13. Gordon PB, Gilks B. Sonographic appearance of normal intramammary lymph nodes. J Ultrasound Med

1988; 7: 545-548.14. Cardeñosa G. Breast Imaging Companion. (2nd Edi). Lippincot: William&Wilkins, 200115. Shaw de Paredes E. Atlas de Mamografía. Madrid: Marban, 1994.16. Travade A, Isnard A, Gimbergues H. Imagerie de la pathologie mammaire. Paris: Masson, 1995.17. Huijung K, Greenberg, Javitt MC. Breast calcifications due to Mönkeberg medial calcific sclerosis.

Radiographics 1999; 19: 1401-1403.18. Sickles EA. Breast calcifications. Mammographic evaluation. Radiology 1986; 160: 289-293.19. Homer MJ, D´Orsi CJ, Sitzman SB. Dermal calcification in fixed orientation. The tattoo sign. Radiology

1983; 192: 592.20. Kopans DB, Meyer JE, Grabbe J. Dermal deposits mistaken for breast calcifications. Radiology 1983;

149: 592.21. Kopans DB. La mama en imagen. Madrid: Marban, 199422. Adler DD, Rebner M, Pennes DR. Accessory breast tissue in the axilla. Mammographic appearance.

Radiology 1987; 163: 709.23. Carter MM, Mc Cook BM, Shoff MI. Case report: dilated mammary veins as a sign of superior vena cava

obstruction. App. Radiol. 1987; 16: 100-102.24. Minagi H, Yonker JE. Roentgen appearance of fat necrosis in the breast. Radiology 1968; 90: 62-65.


23

CHAPTER III

CATEGORY 2. “BENIGN”

F. Martín Díez and M. Coll de la Vega

IntroductionIn the “Benign” category we will include lesions whose radiological characteristics make them

unquestionably benign. These are consequently not going to generate any other procedure or diagnosticaction (1, 2), even though they may require some kind of therapeutic intervention, as occurs withmastitis.

Perhaps amongst all the mammographic categories in our procedure, the Benign group is theone involving greatest responsibility for the reader since, as we have already mentioned, the studyends here, with the woman being given an appointment for a further checkup two years later. On theother hand the Probably Benign, and of course the Probably Malignant and Malignant classificationsinherently involve a new sequence of studies.

It will sometimes prove difficult to consider a particular finding as being a “lesion” and we willtherefore doubt whether to include this in the “Normal” or “Benign” categories, there being anoverlapping area between these which is not actually important, since neither of them will requirefurther studies, with the next checkup having to be made in the previously defined screening interval,which in the case of the VBCSP is every two years. Some examples:

• Small oval-shaped or not very dense nodule.• Calcified liponecrosis and mastitis of plasmatic cells which could be included in either of the two

categories, “Normal” or “Benign” (Fig. 1, page 77).• Small calcified fibroadenoma.Sometimes, when in view of a particular radiological finding we consider a breast from the

radiological standpoint of “Probably Benign” or even “Probably Malignant”, and this will thus entaila particular procedure, either a study with additional projections at the facility itself, a short-termfollow-up or complementary studies to be performed in the reference hospital (ultrasound or biopsy)but after these, we conclude that these are benign lesions and thus in the following checkups thesewill then be included in the category of “Benign” in spite of their appearance. (3-6) A few examplesmight be of use:

• Nodule with a poorly defined contour which by ultrasound, or after the biopsy, draining of theliquid and pneumocystography, corresponds to a cyst (Fig. 2, page 77).

• Asymmetric zones which after follow-up remain stable, or after an ultrasound are proved to bea cyst.

• Group of “probably benign” microcalcifications with a 2-year follow-up, with no changes.• Biopsied solid nodules or asymmetries with benign histological diagnosis.• Star image with mammographies supplied by the patient from over 2 years before, in which this

was already present.The characteristics of a cystic lesion in ultrasound are: anechoic, with a sharp contour and later

reinforcement (Fig. 3 a and b, page 78). In our programme all the nodules that are studied by

24

ultrasound, solid and over 0.5 cm in size have to be considered as being in the “probably benign”category (7-9) (Fig. 4, page 79).

In an initial sample of 61,009 examinations, the benign category includes 27% of themammographies read in our programme, with a positive predictive value (PPV) of “0” for breastcancer. Of the 16,606 readings considered benign, 48.45% were nodules, 41.32% calcifications,6.85% asymmetries, 0.2% structural alterations and in 3.16% of the cases the description of thelesion giving rise to this category was not given.

The reading procedure at the VBCSP could seem to be excessively strict or stringent for a radiologistwell-accustomed to mammographic reading, but it was prepared in an attempt to unify criteria amongstall the facilities, to avoid generating doubts and remove the subjective factor as far as possible. So, forexample, we are aware that there are nodules over 0.5 cm in size but with perfectly well-definedcontours in both projections, that are not very dense, allowing the rest of the parenchyma to be seenthrough these, even not being palpable to clinical examination, and we are sure that these are benignnodules, but by following our procedure strictly, as we will now see, we should consider these asbeing probably benign through their size (Fig. 5, page 79).

Going by the VBCSP reading procedure, with the initial radiological reading we will considerthese to be a “Benign breast”, when we find one of these Radiological Descriptions (10):

NODULE/MASS IN THE “BENIGN” CATEGORY:According to their density these can be considered to be nodules with benign characteristics (2):

01. Water density: To consider a water density nodule as being benign, the following characteristicsshould be found:

- Under 5 mm in diameter.- Low density, homogeneous and transparent.- Sharp contour in all the projections (Fig. 6, page 80).

01. Fatty density: Encapsulated lesions which are wholly radiolucent or which contain islets ofmammary tissue are always benign (11):

- Hamartoma or Fibroadenolipoma: tends to be easy to diagnose since this is characteristicallyseen as a mixed density mass through its double content in radiolucent fatty tissue and densefibroadenomatous tissue, wrapped in a pseudocapsule, well-defined which was defined many yearsago as a “slice of salami” (12) (Fig. 7, page 80). Sometimes the pseudocapsule can be difficult toidentify and may even go unnoticed.

- Lipoma: these are totally fatty lesions, surrounded by a fine capsule sometimes difficult todifferentiate from the normal trabeculations in very fatty breasts. On the other hand, these are seenbetter in breasts with more glandular tissue, allowing one to see the distortion through occupation ofspace which they produce on the neighbouring structures, which sometimes mould them due to theirlow consistency (Fig. 8 a and b, page 81). The lipomas are thus soft and move freely, these beingcharacteristics which may differentiate them from oily cysts and galactoceles, which are harder androunded.

- Galactocele. These are rounded, well-defined nodules, of fatty density, which could sometimesdisplay a level if a middle-lateral projection is made (Fig. 9, page 82), and normally found in aretroareolar location. They tend to be produced in lactation periods or in women with high prolactinlevels.

- Oily cyst. This is the most frequent entity, normally due to post-traumatic fatty necrosis. Theymay be easy to detect clinically by palpation and on the other hand be difficult to show up inmammography (Fig. 10, page 82).

We will also include in this section nodules considered benign when examined the second timeround, since we know that after a first study in which these were included in a higher category, anultrasound or a biopsy was made on them, or that they did not undergo changes after a series ofshort-term follow-ups as referred to earlier, so that from now on these nodules will thus be includedin the Benign category.

25

STRUCTURAL ALTERATION IN THE “BENIGN” CATEGORY:

02. Structural alteration due to traumatism, surgery or infection.The only structural alterations of the parenchyma that we can consider as being benign are due to

postoperative (Fig. 11, page 83), post-traumatic, or post-infectious changes duly proven with overtwo years follow-up with no suspicious evolutionary changes; or if the patient supplies previousmammographies, also from over two years before, in which the finding was already detected, withno evolutionary changes (13). In successive series or reviews in which the same image persists wecould nevertheless consider the mammography as being “without findings”, and thus include this inthe “Normal” category.

Though some authors consider that the typical star image with no dense central nucleus, evenslightly fatty, with long, fine and homogeneous spicula, is characteristic of Sclerosing Ductal Hyperplasiaor Radial Scar, we always consider this as being “Probably Malignant”, and it should never be includedin the “Benign” category, unless there are prior studies from over two years before, no evolutionarychange being observed (14).

CALCIFICATIONS IN THE “BENIGN” CATEGORY:The deposits of calcium in the breast are extremely frequent, always establishing on some prior

histological change (2).

03. Calcified fibroadenoma. Sometimes in dense breasts these are the only sign indicating thatthere is a fibroadenoma there (Fig. 12 a and b, pages 83 and 84).

03. Cystic liponecrosis. These are spherical calcifications produced by an inflammatory processwith fatty saponification and later precipitation of the calcium (Fig. 13, page 84).

03. Granulomas on foreign bodies. This tends to occur in the case of sutures that have also beensubjected to radiotherapy, morphologically seen as parallel calcifications with a tubular or polymorphousappearance (Fig. 14, page 85).

03. Ductal or periductal, very extensive through mastitis of plasmatic cells. These are positioneddown the ductal lines, rarely branched and tend to have a diameter of over 0.5 mm. These are a formof secretory deposit, which will later be calcified, either in normal or dilated ducts, or in the periductalstroma by inflammatory reaction around them (Fig. 15, page 85).

03. Calcium milk in cyst. The calcium precipitates in the cystically dilated acini, coming out in thecraniocaudal projection with a blurred, poorly defined or punctiform appearance which could start tobe considered suspicious, but if the middle-lateral projection is made these will typically be observeddeposited in the most sloping part in the shape of a half-moon, tea cup or simply linear (Fig. 16 aand b, page 86).

The walls of the cysts can also calcify in the form of very fine annular deposits on a water densitynodule, these being characteristics which differentiate them from calcifications of the fatty necrosis.

03. Disperse bilateral microcalcifications with a tendency to symmetrical distribution, and whichdo not form groups (Fig. 17, page 87). We should take great care not to overlook any small group ofmicrocalcifications which is different and might represent some focus of malignancy. Themicrocalcifications which do not keep to a bilateral and symmetrical distribution should be examinedwith magnified projection (15).

ASYMMETRIES IN THE “BENIGN” CATEGORY:04. Asymmetries of the parenchyma.Any asymmetries of the parenchyma due to recent and clear clinical episodes such as traumatisms

or infections which have conditioned the presence of asymmetries very probably due to haematomas


26

or abscesses can initially be considered as benign. But strictly speaking, the benign classificationshould only be given to the asymmetries of the parenchyma or ductal asymmetries which havedisplayed no alterations (Fig. 18 a and b, pages 87 and 88) after a follow-up of at least two years,over which they have been included in the “Probably Benign” category, or if at one of the checkupsbefore this time, we find the typical images of post-traumatic fatty necrosis, or if the “suspicious”findings that entailed follow-up have simply disappeared. This is to say that, to do things properly,any asymmetry should be considered with the initial radiological reading as at least “Probably Benign”,carrying out a physical examination and/or ultrasound.

On other occasions it would be possible to avoid the follow-up of an asymmetry zone which - weinsist - is “Probably Benign” from the initial mammographic reading, if an ultrasound is performed inwhich unquestionably benign findings are seen, such as for example a zone with diverse small cysticformations, or if an FNAB or core needle biopsy is made of the zone, directed by ultrasound, takingseveral samples, and if the report, preferably a histological one, has unquestionably benign findings(16) (Fig. 19 a and b, pages 88 and 89).

Nevertheless, any asymmetry which meets the following conditions can be considered “Benign”or even “Normal” right from the start: if this is not palpable (any asymmetry must be clinicallyexamined) located preferably in the upper-outer quadrants, having a density similar to the rest of theparenchyma, even if it contains zones of fatty density, and is not volumetric, that is if this is onlyobserved in a projection, or disappears with spot compression (17, 18).

ALTERATIONS OF THE SKIN/NIPPLE IN THE “BENIGN” CATEGORY:05. The thickenings of the skin can be of local or general nature (19). Amongst the most frequent

causes of local thickening of the skin we can find the local infection (with or without abscess-forming),the traumatism and postoperative scar (Fig. 20 a and b, pages 89 and 90).

Diffuse thickenings of the skin are more frequent, associated with generalised oedema which mustbe due to both aseptic and bacterial mastitis (Fig. 21, page 90) or to prior radiotherapy. The syndromeof diffuse and bilateral oedema-thickened skin tends to arise through a dermatological cause, congestiveheart failure or kidney failure.

The greatest difficult is involved in being able to differentiate Mastitis from Inflammatory Carcino-ma and Paget’s carcinoma from simple eczema of the nipple, as described in the chapter on the“Malignant” category.

COMBINED/MULTIPLE:06. This radiological description is included to describe two specific situations:- To explain why two or more findings previously described with benign characteristics are present

in the same lesion (this is normally a nodule with calcifications). In this case the two findings combinedwhich will previously have been stated along with the relevant code, will have been separately analysedand both considered benign (Fig. 22, page 91).

- Because one of these findings, of benign characteristics, which will also have been reflectedbeforehand with its corresponding code, is observed in large numbers in the same breast; for example,the multiple nodules of benign characteristics with numerous cysts (Fig. 23, page 91) and/orfibroadenomas.

OTHERS:07. We will mainly use this description to take note that there is some other finding in the

mammography which is not the one giving rise to the classification in the benign category but whichshould be included in a lower group, that is in the “Normal” category; for example, a breast withtypically benign calcifications which also has normal vascular calcifications (Fig. 24, page 92).

27

Bibliography

1. Shaw de Paredes E. Evaluation of abnormal screening mammograms. Cancer 1994; 74: 342-349.2. Homer M. Benign lesions in the breast. In: Mammographic interpretation. A practical approach. New

York. Mc Graw-Hill 1991; 30-56.3. Sickles EA. Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive

cases. Radiology 1991; 179: 463-468.4. Sadowsky NL, Semine AA, Levin E, Kelly E. Ultrasonographic guidance for needle biopsy of breast

lesions. Surg Oncol Clin North Am 1997; 6: 265-84.5. Vizcaino I, Gadea L, Andreo L, Salas D, Ruiz-Perales F, Cuevas D,et al. Sreening Program Working

Group. Short-term follow-up results in 795 nonpalpable probably benign lesions detected at sreeningmammography. Radiology 2001; 219 (2): 475-83

6. Apesteguia L, Pina L, Inchusta M, Mellado M, Franquet T, De Miguel C, et al. Nonpalpable, well-defined,probably benign breast nodule: management by fine-needle aspiration biopsy and long-interval follow-upmammography. Eur Radiol 1997; 7 (8): 1235-9

7. Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: use ofsonography to distinguish between benign and malignant lesions. Radiology. 1995; 196: 123-134.

8. Schepps B, Scola FH, Frates RE. Benign circumscribed breast masses. Mammographic and sonographicappearance. Obstet Gynecol Clin North Am 1994; 21: 519-537.

9. Fornage B, Lorigan J, Andry E. Fibroadenoma of the breast: Sonographic appearance. Radiology 1989;172: 671-675.

10. Generalidad Valenciana. Conselleria de Sanitat. Programa de Prevención de Cáncer de Mama en laComunidad Valenciana. Monografía Sanitaria Serie E, nº19. Valencia: Generalitat Valenciana 1996.

11. Kopans DB. Lesiones benignas y probablemente benignas. En: La mama en imagen. Madrid: Marban1999; 353-356.

12. Riveros M, Cubilla A, Perotta F, Solalinde V. Hamartoma of the breast. J Surg Oncol 1989; 42: 197-200.13. Stigers KB, King JG, Davery DD, Stelling CB. Abnormalities of the breast caused by biopsy: spectrum of

mamographic findings. AJR 1991; 156: 287-291.14. Alleva DQ, Smetherman DH, Farr GH, Cederbom GJ. Radial scar of the breast: radiologic-pathologic

correlation in 22 cases. Radiographics 1999; 19: S27-S35; discussion S36-7.15. Lafontan B, Daures JP, Salicru B, Eynius F, Mihura J, Rouanet P et al. Isolated clustered microcalcifications:

diagnostic value of mammography, series of 400 cases with surgical verification. Radiology 1994; 190:479-483.

16. Fuhrman G, Cederbom G, Champagne J, Farr G, McKinnon W, Bolton J et al. Stereotactic core needlebreast biopsy is an accurate diagnostic technique to assess nonpalpable mammographic abnormalities. JLa State Med Soc 1996; 148: 167-70.

17. Homer M. Localizing signs of breast cancer, en: Mammographic interpretation. A practical approach.New York: Mc Graw-Hill, 1991; 47-54.

18. Kopans DB, Swann CA, White G et al. Asymmetric breast tissue. Radiology 1989; 171: 639-43.19. Kopans DB. Hallazgos asociados: cambios en la piel, pezón y trabéculas y adenopatías axilares. In: La

mama en imagen. Madrid: Ed. Marban 1999; 339-341.


29

CHAPTER IV

CATEGORY 3. “PROBABLY BENIGN”

I. Vizcaíno Esteve

Introduction.Probably benign lesions are described in the reading systems of the VBCSP (1, 2) as non-palpable

lesions which have a low risk of cancer with a Positive Predictive Value (PPV) ranging from 0.3 to1.7% (2-7). This category represents a percentage ranging from 2 to 11% of all mammographicreadings in the first screening round (3-7). According to the readers’ training level and experiencethere will be a greater percentage of probably benign lesions at the start of the readings, which willdrop with experience, and with the availability of prior mammographies in the second and successiverounds. (7, 8).

Sickles defines probably benign lesions as the non-palpable findings in which a short mammographicfollow-up (under the screening interval) is recommended as an alternative to open surgical biopsy orpercutaneous fine or core needle biopsy (8). The probably benign category should not be included inthe positive findings of screening, this being rather a category close to benignity, but in which thepresence of a few malignant lesions means that benignity should be confirmed, by means of a shortmammographic follow-up, generally from 6 to 12 months after the initial screening (7,8). If thelesion grows the procedure should be to go on to complete excisional surgical biopsy (3-7).

Prior to classifying a lesion in the probably benign category, this should be studied by means oflocalised projections in the case of nodules and asymmetries, and with magnified projection formicrocalcifications. Later on, depending on the type of lesion, an additional valuation defined by theclinical examination (9) and the ultrasound (10) can be made. In certain cases definitive normality orbenignity can be established, including the lesions in the relevant categories of 1. NORMAL and 2.BENIGN.

Given the amount of variables to consider in the mammographic signs, certain inaccuracies areinvolved in determining the classification of a lesion as probably benign, nevertheless we have adoptedthe following criteria, based on both the publications existing and on our own data obtained at theVBCSP (3-7):

01. NODULES IN THE “PROBABLY BENIGN” CATEGORY:Non-calcified nodules of any size, in general of 0.5-2 cm, non-palpable, round, oval or lobulated

(with 2 or 3 lobulations) with sharp well-defined contours, fully or partially visible due to superimposingwith the glandular tissue surrounding them, with no fat inside, with or without a halo sign (Fig. 5,page 79; 1 a, page 95; 2 a, page 96; and 3, page 97). Ultrasound is recommended as first valuationof nodules, as this is able to demonstrate the presence of cysts (Fig. 3 b, page 78) or solid lesions withechographic characteristics of benignity (Fig. 4, page 79; 1 b, page 95; 2 b, page 96). Occasionally,intracystic lesions requiring later cytological or histological study can be revealed by means of ultrasound(Fig. 4, page 97).

30

02. CALCIFICATIONS IN THE “PROBABLY BENIGN” CATEGORY:Grouped microcalcifications. The following are considered to be characters of probable benignity:- Forming fairly small groups (of 5-10 particles).- Spherical, round or oval with well-defined contours (Fig. 5, page 98).- Homogeneous in shape, size and density, though it also includes any that reveal variations in size

and density (Fig. 6, page 98).We include in this section punctiform microcalcification and groups of small, amorphous, flaky or

blurred micro-calcifications (Fig. 7, page 99).The descriptions of microcalcifications that are combinations of the previous ones that cannot be

considered as being definitively benign, that are indeterminate or difficult to classify, but with anabsence of signs of malignancy, have also been included in this category (Fig. 8 a and b, pages 99and 100).

03. ASYMMETRY IN THE “PROBABLY BENIGN” CATEGORY:3.1. Asymmetries of the parenchyma, focal, similar to the adjacent parenchyma, with a volumetric

effect (visible in two projections) and which are not modified with spot compression, with no fatinterspersed in these and without the mass effect or associated structural alteration. Generally locatedin areas other than the areolar region or the upper-outer quadrant of the breast.

These are considered to be included in this section when they do not comply with the conditionsstated in the asymmetries of a benign nature or in the asymmetries defined as being probably malignant,recently appearing or in relation to HRT (Fig. 9 a and b, pages 100 and 101). Asymmetries shouldalways be valued by means of palpation and ultrasound. When these are palpable and the ultrasoundreveals a mass one should proceed to percutaneous biopsy (Fig. 10 a and b, pages 101 and 102).

3.2. The asymmetric ductal pattern, viewed as tubular images from the nipple, is also included inthis category. The ultrasound, or the galactography can on occasions reveal the cause of ductalasymmetry (Fig. 11 a and b, pages 102 and 103). Ductal asymmetries should also always be valuedby palpation.

06. COMBINED / MULTIPLEIncludes all possible combinations of probably benign findings, or of the unilateral or bilateral

presence of probably benign, isolated or combined findings. Examples of this are multiple lesions(more than 2) and/or bilateral lesions consisting of nodules (Fig. 12, page 103). Dispersemicrocalcifications (Fig. 13, page 104), or in multiple groups (Fig. 6, page 98) unilateral or bilateralconsisting of particles of the same characteristics are included as benign lesions, and do not have tobe followed up in the short term, since in our series (7) and in other similar ones published (6) no caseof malignancy has been detected. Disperse unilateral or bilateral microcalcifications pose a perceptionproblem, meaning that special attention should be given to reviewing these so as not to confuse anygroup of different characteristics that could represent malignancy.

When there is a combination of these descriptions or simultaneous presence of lesions these areclassified by the most outstanding finding, although each lesion should be individually valued.

07. OTHERSIncludes any additional finding not covered under the normal or benign category which is found at

the same time as probably benign findings.

Conduct generating the “probably benign” categoryUnlike the BIRADS reading system (11), in which after completing the study with image,

complementary projections and ultrasound, if the lesion is considered as being probably benign thisis synonymous of a mammographic follow-up in the short term, in our reading system we considerthe initial mammographic reading (a double reading with consensus) plus the complementaryprojections for classification of a lesion in the probably benign category with the criteria described insections 01, 03, 04 and 06, always having to follow-up the study of the lesion from this classification,

31

with the possibility of making an ultrasound and a later follow-up in the short term (for example:short-term follow-up at six months for a solid nodule with benign characteristics in both mammographyand ultrasound).

Any probably benign lesion should be followed-up to establish definitive benignity. At the VBCSPa «short-term follow-up» procedure of two checkups between rounds at six and twelve months is atpresent recommended (7), proceeding to surgical biopsy in the event of growth of the lesion (Fig. 14a and b, pages 104 and 105). One must take into account that certain calcifications can remainstable in these periods of time and be a carcinoma, which is why surgical biopsy would also berecommended when later modification or growth is seen after the short-term follow-up periods (15)(Fig. 15 a and b, pages 105 and 106). Multiple nodules (solid in ultrasound) probably benign, unila-teral or bilateral, with similar characteristics, are also valued with a short mammographic follow-up toestablish their definitive benignity. Fine-needle biopsy, guided by stereotaxis, coordinates or ultrasoundcould be useful in particular probably benign lesions (16-18) (Fig. 3 page 97; 16 a, b and c, pages106 y 107), though it has been proved that the use of a short-term mammographic follow-up is auseful alternative to value such lesions, with no need to use percutaneous cytological or histologicalsamples (7, 8). Asymmetries in density originally classified as probably benign should always bestudied by means of palpation and ultrasound to objectify/ discard mass, making a later cytological orhistological study if required, and are never included in the short-term follow-up procedure (Fig. 17 aand b, page 108).

The use of core needle biopsy has been suggested in probably benign lesions in women who fordifferent reasons cannot follow-up the short-term checkups, or who themselves request a histologicalanalysis (19), but the cost-effectiveness ratio of this technique in these low risk lesions is beingquestioned (20).

The microcalcifications defined by us as probably benign lesions constitute a very heterogeneousgroup which is at present being reviewed to correlate the histological findings, as the benigncalcifications also progress in the short-term follow-up and require surgical excision reducing thePPV of the biopsies (Fig. 8 a and b, pages 99 and 100) (7).

According to our experience in a valuation of 13,790 women at the VBCSP, studied in the firstround of the screening, the lesions classified as probably benign came to 795 (5.8% of the total ofwomen screened), of which 242 (31%) were nodules, 471 (59%) microcalcifications and 82 (10%)asymmetries, and the PPV of these probably benign lesions was 0.3% (7).

Bibliography

1. Generalidad Valencia. Conselleria de Sanitat. Programa de Prevención de Cáncer de Mama de la Comu-nidad Valenciana. Monografía Sanitaria Serie E, nº 25. Valencia: Generalitat Valenciana 1998.

2. Vizcaíno I, Salas D, Vilar JS, Ruiz-Perales F, Herranz C, Ibañez J et al. Breast Cancer Screening: FirstRound in the population-based Program in Valencia, Spain. Radiology 1998; 206: 253-260.

3. Sickles EA. Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutivecases. Radiology 1991; 179: 463-468.

4. Wolfe JN, Buck KA, Salane M, Parek NJ. Xeroradiography of the breast: overview of 21,057 consecutivecases. Radiology 1987; 165: 305-311.

5. Helvie MA, Pennes DR, Rebner M, Adler DD. Mammographic follow-up of low-suspicion lesions: compliancerate and diagnostic yield. Radiology 1991; 178: 155-158.

6. Varax X, Leborgne F, Leborgne JH. Nonpalpable, probably benign lesions: role of follow-up mammography.Radiology 1992; 184: 409-414.

7. Vizcaino I, Gadea L, Andreo L, Salas D, Ruiz-Perales F, Cuevas D, et al. Screening Program WorkingGroup. Short-term follow-up results in 795 nonpalpable probably benign lesions detected at screeningmammography. Radiology 2001; 219 (2): 475-83

8. Sikles EA. Probably benign lesions: when should follow-up be recommended and what is the optimalfollow-up protocol? Radiology 1999; 213: 11-14.

9. Homer MJ. Imaging features and management of characteristically benign and probably benign breastlesions. Radiol Clin North Am 1987; 5: 939-951.


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10. Cilotti A, Bagnolesi P, Moretti M, et al. Comparison of the diagnostic performance of high-frequencyultrasound as a first- or second-line diagnostic tool in non-palpable lesions of the breast. Eur Radiol 1997;7: 1240-1244.

11. American College of Radiology (ACR). Breast Imaging reporting and data system (BI-RADS™). ThirdEdition. Reston [VA]: American College of Radiology; 1998.

12. Brenner RJ, Sickles EA. Acceptability of periodic follow-up as an alternative to biopsy for mammographicallydetected lesions interpreted as probably benign. Radiology 1989; 171: 645-646.

13. Sickles EA. Management of probably benign breast lesions. Radiol Clin North Am 1995; 6: 1123-1130.14. Dawson JS, Wilson ARM. Short-term recall for “probably benign” mammographic lesions detected in a

three yearly screening programme. Clinical Radiology 1994; 49: 391-395.15. Hall FM, Homer MJ. Mammographic follow-up of clustered microcalcifications. A letter to editor and

reply in AJR 1995; 1550-1551.16. Apesteguía L. Pina L. Inchusta M et al. Nonpalpable, well-defined, probably benign breast nodule:

management by fine-needle aspiration biopsy and long-interval follow-up mammography. Eur Radiol 1997;7: 1235-1239.

17. Azavedo E. Svane G. Auer G. Stereotactic fine-needle biopsy in 2594 mammographically detected non-palpable lesions. Lancet 1989; 1033-1036.

18. Fornage BD. Guided fine-needle aspiration biopsy of non-palpable breast lesions: calculation of accuracyvalues. (Letter to Editor). Radiology 1990; 3: 884-885.

19. Sickles EA, Parker SH. Appropriate role of core breast biopsy In the management of probably benignlesions (editorial). Radiology 1993; 188:315.

20. Brenner RJ, Sickles EA. Surveillance mammography and stereotactic core breast biopsy for probablybenign lesions: a cost comparison analysis. Acad Radiol 1997; 4: 419-425.

33

CHAPTER V

CATEGORY 4. “PROBABLY MALIGNANT”

L.A. Andreo Hernández, L. Gadea Boronat, MªJ. Fuster Selva,C. Ortí Tarazona and F. Ardoy Ibáñez.

IntroductionCategory 4 refers to lesions with mammographic findings very suspicious of malignancy, although

the image and the pathological anatomy cannot be fully correlated, since this appearance can befound, albeit more seldom, in benign lesions (1). In our Programme, on an initial sample of 61,009mammographic examinations, 155 (0.25%) were put into this category.

The lesions should have what we call the “volume effect”, that is, these should be seen to have athree-dimensional structure recognisable in two projections, since the superimposing of normal breaststructures can take on the suspicious appearance of a false star or nodule. Further projections suchas spot compression or magnification help to confirm the existence of the lesion, and to decide as toits possible suspiciously malignant appearance (2).

One of the suspicious characteristics may only prove to be visible in one of the projections made,as occurs in some cases of partially poorly defined contour or in rare cases of masses or flat lesionsin star-form, which may reveal a smaller diameter in one of the projections (Fig. 1 a and b, page111). Here too localised mammographies and further projections are of use, or rotating the breastclockwise or anti-clockwise (3).

When we say that an image is probably malignant we are stating that this is a lesion for which wemust in all cases obtain a histopathological diagnosis. The mammographic differentiation betweenbenign and malignant lesion depends to a large extent on the reader’s experience and the strictnessin the interpretation of the lesions included in this section (4,5). In the initial activity of our Programme(1992) the PPV for the probably malignant category was 46.57%, that is, a cancer was diagnosed inpractically one of every two cases in which this reading was made.

The procedure to be used to come to the diagnosis will depend on the type of lesion, being ingeneral preferable, whenever this is possible to carry out biopsy since these are lesions which involvea high probability of malignity. As to the method used for obtaining the sample, core biopsy orFNAB, there is no unanimous agreement (6-9), depending in many cases on the availability of thetechnical and human resources at each facility, as well as the location and characteristics of thelesion.

We will now go over the Radiological Descriptions of the lesions classified in the “ProbablyMalignant” category (1).

NODULES IN THE “PROBABLY MALIGNANT” CATEGORY:01. Nodules/Masses. We use the probably malignant classification for nodules of any size, generally

of high density, which have a poorly defined, spiculated, irregular, polylobulated or microlobulatedappearance (Fig. 2, page 112), and which may or may not have an extension in comet-tail shape(Fig. 3, page 112). In our screening programme nodules or masses made up 44.5% of the probablymalignant lesions, either as nodules with an irregular (27.7%) or spiculated (16.7%) contour.

34

Finding a nodule in a screening mammography is always relevant, and its nature should be accuratelydetermined. First of all there has to be a systematic analysis of its characteristics to classify this in oneof the categories diagnosed and mark out a later approach. Some of these characteristics are thesize, location and density, as well as the shape. But particular importance must be given to analysingthe contour, as when this is poorly defined or spiculated there is a high risk of the lesion beingmalignant (10). The presence of longer or shorter spicula at the edge of the lesion is a particularlysuspicious sign. When the spicula are small-sized these are called “brush-edged” (Fig. 4, page 113).

At times it occurs that spiculation in the contour of a nodule is not similarly apparent in all theprojections, which is the reason for the importance of the double projection and of the furtherprojections, whenever something suspicious is seen at the edge of a nodular lesion (Fig. 5 a and b,pages 113 and 114). One must furthermore bear in mind that the blurredness, irregularity, spiculationor poor definition of one part of the contour, confirmed by several projections and with spotcompression, is already a criterion for classifying this as Probably Malignant (Fig. 6 a and b, pages114 and 115).

This category therefore includes all the nodules or masses with a spiculated (Fig. 7 a and b, pages115 and 116), or ill-defined contour (Fig. 8, page 116), whatever their size, density or shape is.When a nodule is small-sized or is found in a dense breast which partially conceals this, spot compressionwith or without magnification may improve viewing of its edges (Fig. 9 a and b, page 117). Largepalpable nodules with spiculated contours should be considered as being in the Malignant categoryeven though these are the only sign. Some benign pathologies may display poorly defined contoursand even spiculation, such as cicatricial fibrosis, fatty necrosis, elastosis and infrequent tumours suchas extra-abdominal desmoids and granular cell tumours (11). Nevertheless there is no mammographicsign allowing a differentiation to be made between these lesions and a malignant neoplasia, which iswhy, as previously said, the finding of a nodule of these characteristics requires a biopsy to be madein all cases.

Lobulated contour nodules, especially when the lobulations are numerous and small, also involvea high degree of suspiciousness of malignancy (10), the microlobulated contour having been associatedwith high mucin content tumours (12) (Fig. 10, page 118). Other signs may be found in connectionwith the desmoplastic effect of malignant tumours, such as the retraction of the surroundingparenchyma or a “comet-tail” extension (Fig. 3, page 112).

As regards density, it is important to bear in mind that this depends to a large extent on the sizeof the tumour, and that it is not infrequent to find small sized and low density malignant tumours (Fig.11 a and b, page 119). Although the malignant nodules are generally denser than the benignantones of the same size (13), this characteristic is not a determining factor in the approach to be takenwhich is why, for example, a recently appearing low-density solid nodule should be biopsied.

It is important to remember that some malignant tumours may occasionally have a well-definedcontour, examples of these being the mucinous or colloid carcinoma (Fig. 12, page 120), the medullary,papillary and ductal carcinoma (14), and that the ultrasound and the FNAB are ideal techniques forstudying the nature of these lesions.

STRUCTURAL ALTERATION IN THE “PROBABLY MALIGNANT” CATEGORY:02. Stars. When the mammographic finding is an alteration of the structure in a star-shape this is

always classified as being a probably malignant lesion (Fig. 13, page 120).A “star” shaped lesion is an area of distortion of the mammary architecture with irregular edges

and which takes on a radiated morphology, with no central tumoral nucleus. This is a mammographicfinding which can be a consequence of a great variety of processes, both benign and malignant, themost frequent ones being carcinoma, the radial scar, sclerosing adenosis, fatty necrosis andpostoperative alterations, apart from the infectious pathology (4, 15). The 4.7 % of the images readas probably malignant at the VBCSP were “stars”.

Since most of the structural alterations in “star” form are malignant neoplasias and thatmammographic criteria of benignity and malignancy do not allow a specific diagnosis, we classifythese lesions as being probably malignant in all cases, thus requiring a biopsy (16). As was said above

35

on the matter of Benign lesions, only when there is a documented traumatic or surgical record withmammographies can a conservative approach be taken by mammographic control.

In dense breasts it may occur that the distortion is appreciated without the radiated morphologybeing clearly seen, meaning that it is very useful to use spot compression, which will display the starin many cases (Fig. 14 a and b, page 121).

02. The structural alteration of the breast architecture may be found in a zone with no associatedmass. The mammographic finding is subtle and may go unnoticed if the different projections are notthoroughly and symmetrically compared. The most common cause of architectural structural alterationwith no mass is postoperative scarring, and the most important differential diagnosis carcinoma,especially infiltrating lobular carcinoma (17) (Fig. 15 a, b and c, pages 122 and 123).

CALCIFICATIONS IN THE “PROBABLY MALIGNANT” CATEGORY:03. Microcalcifications. Microcalcification is the term given to calcifications of under 0.5 mm in

size (18), and often an early sign of breast cancer, which turns them into a finding of great importancein the screening mammography. The microcalcifications with characteristics of malignancy, groupedor with regional or segmentary distribution, heterogeneous in shape, size and density, intraductal,vermiform, granular, with irregular contour and poorly defined, are classified as probably malignant.In our case they made up 16.8% of the lesions read as probably malignant.

In population screening studies, 90% of the non-palpable in situ carcinomas and 70% of thecarcinomas under 0.5 cm in size could be detected thanks to viewing microcalcifications as the onlysign (19, 20). Due to their small size it is essential to obtain magnified mammographies in order tomake a proper analysis of their morphology (21, 22), to allow them to be attributed to the probablymalignant category (23) (Fig. 16 a and b, pages 123 and 124).

Calcifications which we can consider typical of breast cancer are small, in groups and with alinear, curved or ramified morphology (18) (Fig. 17, page 124). The pleomorphic appearance of thegroups is an important fact, given that malignant calcifications tend to display marked heterogeneityas regards shape, size and density (Figs. 18 and 19, page 125). In a study of 400 cases ofmicrocalcifications B. de Lafontan and colleagues saw that this criterion of pleomorphism, alongwith the vermicular and ramified or linear morphology, allowed 90% of carcinomas to be properlydiagnosed (24). Distribution is not a definitive criterion for assigning a high or low degree of suspicion,although groups - above all when these are highly numerous and small, granular (Fig. 20, page 126),and a segmentary distribution suggesting calcium deposits in a duct and its branches - raise the levelof suspiciousness and should make one value the possibility of a biopsy (Fig. 21 and 22, pages 126and 127). When these deposits are very numerous, affecting a large part of the breast, with verydiverse shapes, sizes and density of the calcifications, these should be classified as malignant categorylesions.

In screening mammography the concept of stability is important, meaning that if an image doesnot change its appearance over time, we can assume that this is a benign process. Cases havenevertheless been described of stable malignant microcalcifications in a follow-up of over 5 years,this being more frequent in the in situ ductal carcinoma than in infiltrating carcinoma (25). Similarly,the increase in size of calcifications or the appearance of new ones does not necessarily implymalignancy, as this may occur in benign lesions such as adenosis. Therefore, whilst still being important,the stability of microcalcifications is not a definite factor in every case, the analysis of the shape anddistribution of these being more decisive (22).

ASYMMETRY IN THE “PROBABLY MALIGNANT” CATEGORY:04. Tumoral asymmetry. Tumoral type asymmetrical densities, with mass effect, associated with

structural alteration or malignant type microcalcifications (Fig. 23 a and b, page 127 and 128) areconsidered to be probably malignant asymmetries.

Although tissular asymmetry is a very frequent finding, generally these are fibroglandular remains,without exploratory findings or tumoral appearance. The asymmetry of tumoral appearance is a rarefinding (26), only representing 1.3% of the lesions of this category (Fig. 24, page 128), and tends to


36

be seen as a tumour, palpable or not, located in a zone where it is not customary to find tissularremains (4).

The procedure to be implemented in view of a suspicious asymmetry depends on its clinicalpresentation, and in all cases a physical examination of the breast should be made as first step. If theasymmetry is palpable a sample should be taken of this. In the event of a non-palpable asymmetryvisible in ultrasound, this can be used as guidance for performing a FNAB or core biopsy (27) (Fig. 25a, b and c, pages 129 and 130).

COMBINED/MULTIPLE:06. This section includes the simultaneous unilateral or bilateral presentation of isolated, probably

malignant findings. The joint presentation of several probably malignant lesions, such as a star withmicrocalcifications and cutaneous retraction, for example, is considered to be a malignant lesion,which is why it is not included in this description. There are nevertheless times when these findingsare faint, involving a combination of signs which may be classified as probably malignant, dependingon the reader’s experience. On these occasions one cannot be sure that the lesion is malignant eventhough this appears in combination, and it should thus be included in this category.

In most cases, this involves the appearance in one or both breasts of two or more lesions, each ofwhich can be classified as probably malignant, whether these be stars, nodules or groups ofmicrocalcifications. One must bear in mind that in nearly 15% of cases the carcinoma is multifocal ormulticentral at the time of its mammographic detection (28) (Fig. 26, page 130).

OTHERS:07. As occurs with the other categories, this section includes the findings of normal, benign or

probably benign categories, which are presented simultaneously with the probably malignant findings.To make as complete a reading as possible of the mammography note is taken of these findings

of lesser pathological importance under the heading “07. Others”.

Conduct generated by the “probably malignant” categoryAs mentioned, reading a lesion as probably malignant implies in all cases getting a procedure

under way to enable a histological sample of this to be obtained. The woman should be sent to theReference Hospital to have the histopathological diagnosis made.

With the precautions previously stated, and bearing in mind that each case must be studiedindividually, general patterns of action can be established according to the mammographic imageinvolved:

- Nodule/mass. A FNAB or core biopsy is carried out and in the event of the item not beingpalpable this will be guided by ultrasound. In the rare cases in which the nodule is not palpable and isnot visible echographically either, biopsy or FNAB by stereotaxy or surgical biopsy after location witha harpoon or hookwire will be appropriate options.

- Stars. An excisional biopsy should always be performed, since we do not have any guarantee ofgetting a suitable sample of the lesion when a core biopsy is made and even less with a FNAB.

- Microcalcifications. In this case, through being generally non-palpable lesions, the alternativesare excisional biopsy and core biopsy guided by stereotaxy.

- Asymmetries. If the asymmetry is palpable a FNAB or a core biopsy should be performed. If thisis not so, it will depend on whether this is echographically visible, in which case a FNAB or guidedcore biopsy should be attempted, When the lesion is not palpable nor echographically visible one hasto resort to an excisional biopsy by means of pre-surgery location.

N.B.– All the cases described in the figures of this chapter correspond to histologically provencarcinomas.

37

Bibliography

1. Generalidad Valenciana. Conselleria de Sanitat. Programa de Prevención de Cáncer de Mama en laComunidad Valenciana. Monografía Sanitaria. Serie E, nº25. Valencia: Generalitat Valenciana.1998.

2. Shaw de Paredes E. Radiographic Breast Anatomy: Radiological Signs of Breast Cancer. RSNA CategoricalCourse in Physics Technical Aspects of Breast Imaging. Syllabus 1992; 31-42.

3. Kimme-Smith C, Bassett LW, Gold RH. Workbook for Quality Mammography. Baltimore: Williams &Wilkins. 1992.

4. Homer MJ. Mammographic interpretation. A Practical approach. Day W, Navrozov M, eds. New York.Mc Graw-Hill Inc.1991.

5. Svane G, Potchen EJ, Sierra A, Azavedo E. How to Interpret a Mammogram. En: Patterson A, ed.Screening Mammography: breast cancer diagnosis in asymptomatic women. St. Louis Mo: Mosby YearBook, 1993; 153.

6. Evans, WP. Stereotaxic Fine-Needle Aspiration and Core Biopsy. RSNA Categorical Course in BreastImaging. Syllabus 1995; 151-160.

7. Parker SH, Burbank F, Jackman RJ, Aucreman CJ, Cardenosa G, Cink TM et al. Percutaneous large-corebreast biopsy: a multi-institutional study. Radiology 1994; 193: 359-364.

8. Dowlatshahi K, Yaremko ML, Kluskens LF, Jokich PM. Nonpalpable breast lesions: findings of stereotaxicneedle-core biopsy and fine-needle aspiration cytology. Radiology 1991; 181: 745-750.

9. Dershaw DD. Stereotaxic Breast Biopsy. Semin Ultrasound, CT MR 1996; 17: 444-459.10. Adler DD. Mammographic Evaluation of Masses. RSNA Categorical Course in Breast Imaging. Syllabus

1995; 107-116.11. Kopans DB. Breast Imaging. Philadelphia: Lippincott Company, 1993.12. Conant EF, Dillon RL, Palazzo J, Ehrlich SM, Feig SA. Imaging findings in mucin-containing carcinomas

of the breast: correlation with pathologic features. AJR 1994; 168: 821-824.13. Jakson V, Dines KA, Bassett LW, Gold RH, Reynolds HE. Diagnostic importance of the radiographic

density of noncalcified breast: analysis of 91 lesions. AJR 1991; 157: 25-28.14. Bassett LW, Jahanshahi R, Gold RH, Fu YS. Film-Screen Mammography. An Atlas of instructional cases.

London: Dunitz 1991.15. Tabár L, Dean PB. Teaching atlas of Mammography. Stuttgart. Thieme Verlag 1983.16. Svane G, Potchen EJ, Sierra A, Azavedo E. Stellate lesions. In: Patterson A. ed. Screening Mammography.

Breast Cancer Diagnosis in Asymptomatic Women. St. Louis Mo: Mosby Year Book, 1993.17. Andersson I. Introduction to Mammography. Sweden; NICER Publication 1992.18. Sickles EA. Breast calcifications: mammographic evaluation. Radiology 1986; 160: 289-293.19. Feig SA, Shaber GS, Patchefsky A. Analysis of clinically occult and mammographically occult breast

tumors. AJR 1974; 121: 846-853.20. Moskowitz M. The predictive value of certain mammographic signs in screening for breast cancer. Cancer

1983; 51: 1007-1011.21. Sickles EA. Further experience with microfocal spot magnification mammography in the assessment of

clustered breast microcalcifications. Radiology 1980; 137: 9.22. Feig SA. Mammographic evaluation of calcifications. RSNA Categorical Course in Breast Imaging. Syllabus

1995; 93-105.23. Haehnel P, Kleitz C, Looringhe GC. Mammographical Magnification. Imaging of the Breast: an Update.

Categorical Course ECR’93. Syllabus 1993; 29-32.24. Lafontan B, Daures JP, Salicru B, Eynius F, Mihura J, Rouanet P et al. Isolated clustered microcalcifications:

Diagnostic value of mammography-series of 400 cases with surgical verification. Radiology 1994; 190:479-483.

25. Lev-Toaff AS, Feig SA, Saitas VL, Finkel GC, Schwartz GF. Stability of malignant breast microcalcifications.Radiology 1994; 192: 153-156.

26. Adler DD, Helvie MA, Ikeda DM. Nonpalpable, probably benign breast lesions: Follow-up strategies afterinitial detection on Mammography. AJR 1990; 155: 1195-1201.

27. Jackson VP, Reynolds HE, Hawes DR. Sonography of the Breast. Semin Ultrasound, CT MR 1996; 17:460-475.

28. Sickles EA. Mammographic features of 300 consecutives nonpalpable breast cancers. AJR 1986; 146:661-663.


39

CHAPTER VI

CATEGORY 5. MALIGNANT

F. Ruiz Perales, A. Hernández Jiménez and M. Montes Avila.

IntroductionThis category includes images which are the combination of probably malignant lesions associated

with one another and also simple or combined probably malignant lesions, with thickening or retractionof the skin, nipple or pectoral muscle.

Single lesions whose size and morphology involve clear signs of malignancy should also be includedin this category. We refer mainly to high density spiculated masses and to widespread diversemicrocalcifications with morphological characteristics of malignancy.

Also included in this category are the associations of a probably malignant or malignant lesionwith the presence of axillary adenopathies whose size, density, morphology or contours mean thatthese are considered pathological.

Although women’s participation in a screening programme requires that these should beasymptomatic, this requirement is sometimes more theoretical than real, for many causes, one of themost frequent of these being a lack of health information, which means that some women haveundervalued their symptoms, interpreted these wrongly or not given them due importance.

Some of the cancers included in this category are clinical, above all the ones involving alterationsof skin and nipple. These involve clinical signs that are sometimes subtle and revealed through theoperations carried out during clinical examination but that are on other occasions very evident.

In this category we include inflammatory carcinoma, which develops with signs in the skin andPaget’s carcinoma, with eczema of the nipple. In these carcinomas the clinical signs are often moreevident than the radiological ones.

NODULE / MASS IN THE MALIGNANT CATEGORY5.1. – Nodule or mass, with spiculated contours, often associated with microcalcifications with

signs of malignancy with or without alterations in the skin, nipple or pectoral muscle, associated onoccasions with axillary adenopathies.

Many breast carcinomas, especially ones with ductal origins, are seen in radiology as nodules,normally of high density, with spiculated contours (1). The spiculations can be short or long, ofdifferent thickness, and reflect zones of fibrosis in relation with the desmoplastic reaction whichprovoke some tumours on the healthy surrounding tissue. In these we can find microscopicallytumoral cells (2). These spiculations can even contact the skin or the pectoral muscle, making thesethicken and retract (Fíg.1 and 2). When the mass or stellate nodule is in a retroareolar location, itmay condition a retraction of the nipple (Fig.3). There are occasionally associated microcalcificationswith malignant radiological characteristics, the diagnosis of malignancy being practically certain inthese cases (Fig. 4 and 5).

40

STRUCTURAL ALTERATION IN THE MALIGNANT CATEGORY5.2. – Tumoral structural alteration, associated with tumoral asymmetrical density, malignant

microcalcifications and occasionally alterations of the skin or nipple.The pattern for the architecture of normal glandular tissue assumes a morphology which conver-

ges from the periphery towards the nipple, following the direction of the galactophorous ducts.When this arrangement is altered, and the mammography reveals part of the glandular tissue aimingat a point other than the nipple, this can be described as a distortion of the glandular architecture. Onoccasions, it is the fibres which are altered, increasing in number, in size and also in direction, andseen as an image converging on a point, which is known as the stellate image.

This type of radiological presentation can also be caused by benign lesions such as fatty necrosis,postoperative scarring and other pathologies such as sclerosing adenosis or radial scars. Every alterationin structure have to be considered probably malignant, unless the case history record points onetowards a scar caused by prior surgery or fatty necrosis through traumatism or reductive surgery.

The readings which put a lesion into the malignant category are the association of a structuralalteration, with no prior traumatic case history, with radiologically malignant microcalcifications (Fig.6), or with a thickening and retraction of the skin or nipple, as well as the presence of axillaryadenopathies.

CALCIFICATIONS IN THE MALIGNANT CATEGORY5.3. – Widespread microcalcifications with signs of malignancy. Diverse shapes, linear,

vermiform or branched with irregular contours, along with other granular microcalcifications ofdifferent sizes and variable density.

ASYMMETRIES IN THE MALIGNANT CATEGORY5.4. – Tumoral asymmetry, associated with structural alteration, microcalcifications, with signs

of malignancy, thickening and retraction of the skin or nipple, and occasionally axillary adenopathies.This form of asymmetry, which should be studied comparatively with the contralateral breast, has

poorly defined limits and is often associated with the alteration of the structure, this being moreevident than density asymmetry in dense breasts, while in fatty breasts density asymmetry is moreevident. On occasions palpation is positive.

This form of presentation of breast cancer is less frequent than the ones previously reviewed.The radiological image will reveal a zone of greater density in comparison with the same zone of thecontralateral breast, which tends to be displayed in the two routine projections (CC and MLO),though occasionally it is only visible in one of these. The densest zone is in the centre of the lesion,gradually attenuating towards the periphery.

We will consider a zone of asymmetrical malignant density, when this is palpable and is associatedwith alteration of the glandular architecture, microcalcifications with signs of malignancy, or withthickening and retraction of the skin. (Fig.7 a and b).

ALTERATIONS OF THE SKIN AND NIPPLE IN THE MALIGNANT CATEGORY

5.5. – Alterations of the skin and nipple. Includes clinical-radiological diagnosis items:5.5.1. – Inflammatory carcinoma:Inflammatory breast cancer is an infrequent variety of locally advanced breast cancer (3). Its diag-

nosis is made by jointly valuing the clinical, radiological and histological findings, the first being ofspecial relevancy, both in this type of tumour and in Paget’s disease.

Clinically this tends to be seen as an increase in size of the breast with a change in the skincolouring, which may vary from a reddish or violet shade with ecchymotic appearance, in at leastone third of the breast (4-6), or appear as “peau d’orange”, thus known through the appearanceconditioning an increase in the depressions surrounding the hair follicles as a result of the presenceof oedema of the skin (9) (Color photo 1). The breast is sensitive and reacts painfully when examined,it being possible to palpate a real mass or a zone induration. There may also be an increase intemperature and retraction of the nipple. It is common to find homolateral palpable axillar adenopathies

41

(5, 6, 8). In very advanced stages there is cutaneous ulceration. This form of clinical presentation ofbreast cancer can be brought about by any of the histological types which cause mammary carcino-ma, but to make a diagnosis of inflammatory carcinoma it is essential that the dermic lymphaticsshould display tumoral invasion in the histological study (3).

From the radiological standpoint the collection of mammographic findings of tumoral density ormass associated with inflammatory changes such as thickening of the skin (Fig. 8), overall increase inthe density and diffuse trabecular thickening should make one think of inflammatory carcinoma (Fig.9 a and b), (8). When we only find inflammatory signs this will probably be some other pathologysuch as: mastitis, mammary abscess, breast subject to conservation treatment with recent radiationor surgery, lymphomas, pseudolymphomas, or metastatic disease which may cause primary affectionof the breast through direct infiltration or secondary affection through lymphatic obstruction throughmalignant nodes axillary pathology (4).

5.5.2. – Paget’s diseaseThis is a special variant of ductal carcinoma, in which the tumoral cells extend distally through the

galactophorous duct to the epithelial surface of the nipple (9). The age at which this occurs is overthat of other types of breast cancer, its maximum incidence being at over seventy-six years of age.

Patients tend to have eczematic changes in the nipple which may be impossible to distinguishfrom non-tumoral etiology nipple eczema. (Color photo 2) (9-11).

Radiologically the mammography can be normal, or reveal a thickening of the nipple-areolacomplex, a dilated duct, calcifications of malignant type, as mass in retroareolar location (Fig. 10) orin any situation of the breast. Occasionally there may be telorrhagia, with this occurring when thebreast is compressed to perform a mammography (9, 12).

It should be stressed that the clinical appearance of the nipple has nothing to do with the radiologicalpresence or absence of underlying carcinoma and thus a negative mammography in the presence ofsuspicious clinical alterations in the nipple does not exclude the diagnosis of Paget’s disease (9, 10).

COMBINED/ MULTIPLE5.6. – All the lesions included in the Malignant Category are combinations of probably malignant

lesions, with or without alterations of the skin, nipple, retraction of the pectoral muscle and occasionallywith axillary adenopathies.

There are nevertheless combinations of small-sized probably malignant lesions, which are knownas minimum signs, that may be associated and difficult to make out. In these cases, in spite of thecombination of lesions, these should continue to be included in the probably malignant category.

5.6. – The lesions included in the Malignant Category can be multiple and be located in one orboth breasts.

OTHERS5.7. – Includes any finding in the normal, benign or probably benign category, which is found

simultaneously with the findings of the Malignant Category.

CONDUCT GENERATED BY THE “MALIGNANT CATEGORY”In every case it is compulsory to obtain a cytological/histological analysis of the lesion, either

through core biopsy or surgery according to the protocols of the multidisciplinary breast committeesof the reference hospitals, to decide on the appropriate therapeutic strategy (chemotherapy,radiotherapy and surgery). In Paget’s disease, a smear of the nipple may be useful, and in inflammatorycarcinoma, biopsy of the skin to verify the neoplastic infiltration.

N.B. – All the cases described in the figures in this chapter are histologically verified carcinomas.

CATEGORY 5. “MALIGNANT”

42

Bibliography

1. Tabár L. Dean PB. Stellate/Spiculated lesions. In: Teaching Atlas of Mammographie. (3rd edi.). New York:Thieme 2001; 93-96.

2. Kopans DB. Apariencia mamografica del cáncer de mama. In: La mama en imagen. Madrid: Marban1999; 377-380.

3. Dershaw DD, Moore MP, Liberman L, Deutch BM. Inflammatory breast carcinoma: mammographicfindings. Radiology 1994 Mar. 190: 831-34.

4. Jaiyesimi IA, Buzdar AU, Hortobagyi G. Inflammatory breast cancer: a review. J. Clin. Oncol. 1992; 10:6, 1014-24.

5. Berger SM. Inflammatory carcinoma of the breast. AJR 1962; 88: 1109-16.6. Tardivon AA; Viala J; Corvellec A; Guinebretiere JM; Vanel D. Mammographic patterns of inflammatory

breast carcinoma: a retrospective study of 92 cases. Eur.J.Radiol. 1997; 24: 2, 124-30.7. Kopans DB. Carcinoma inflamatorio de mama. In: La mama en imagen. Madrid: Marban 1999; 590-

591.8. Shaw de Paredes E. Atlas de Mamografia. Madrid, Ed Marban 1994; 451-52.457.9. Sawyer RH; Asbury DL: Mammographic appearances in Paget´s disease of the breast. Clin. Radiol 1994;

49: 3, 185-88.10. Ikeda DM; Helvie MA; Frank TS; Chapel KL; Andersson IT. Paget’s disease of the nipple: radiologic-

pathologic correlation. Radiology 1993; 189: 1, 89-94.11. Jamali FR; Ricci A Jr.; Deckers PJ. Paget´s disease of the nipple-areola complex. Surg. Clin. North.Am.

1996; 76: 2, 365-81.12. Dixon AR; Galea MH; Ellis IO; Elston CW; Blamey RW. Paget´s disease of the nipple. Br. J. Surg., 1991;

78: 6, 722-3.

43

CHAPTER VII

MISCELLANEOUS

T. García Redón, M. Redondo Ibáñez, R. Piqueras Olmeda and J. Núñez de Bobadilla.

IntroductionThis chapter includes the description of artefacts, some relatively common, such as the ones

caused by creams or deodorants which may lead to errors in the mammographic reading. It alsodescribes the foreign bodies which may be found after earlier surgery or arise accidentally.

The increasing use of plastic surgery and mammary reconstruction surgery means we have toknow some data about specific mammographic findings connected with materials and techniquesused. Lastly, this chapter includes the description of some seldom found malignant tumours, bothprimary and metastatic.

Artefacts and superpositionCertain substances applied on the skin may be radio-opaque and suggest microcalcifications, such

as creams or ointments which include zinc oxide (1, 2) in their composition. Deodorants and talcumpowders have similar characteristics and may also appear, mimicking calcifications. Artefacts producedby soaps which contain additives such as barium sulphate, sodium and potassium hydroxide havebeen described, as well as ones occurring simply through washing with very hard waters rich incalcium salts (3). These appear as very fine granular densities on the surface of the breasts or inaxillary or inframammary folds (Fig. 1, page 143). If there is any clear suspicion the zone should bewashed thoroughly and the mammographs repeated.

The gold salts administered via intramuscular injection to rheumatoid arthritis develop gold depositsin intramammary and axillary lymph nodes which mimic microcalcifications (1).

Tattoo marks on the skin may also appear to be microcalcifications (3).Other artefacts such as fingerprints on the films, dust on the screens or hair superposed on the

mammary parenchyma are easily recognised (4).Topically administered antimitotic (5-fluoracil) abrasive substances may provoke cutaneous ulcers,

which might be confused with ulcerations inside a carcinoma (we include a case of self-lesions withEfudix) (Photo 1, page 143).

Foreign bodiesForeign bodies such as needles (Fig. 2, page 144), pieces of glass, pencil points or projectils (Fig.

3, page 144) and others (2) are occasionally found, whether the patients are aware of these or not,but nevertheless asymptomatic.

Sutures, which may calcify after surgical biopsies, tumorectomies, reductive mammoplasties, willbe seen as calcifications, linear or in knot form (Fig. 4, page 145), (5). The location of the surgicalscar must be correlated with the calcification zone.

Some of the complications reported in the use of hook wires for biopsies of non-palpable lesionsare the breakage and loss of fragments inside the breast (Fig. 5, page 145), meaning that if the

44

fragment is not recovered or identified after surgery, a mammography must be carried out to look forthis as soon as possible and verify the stability of the fragment in series of mammographies afterthree and six months. This approach is logical since intramammary fragments are usually asymptomaticand their location will require placing a second hook wire and further surgery. No complications withfragments of hook wires have been described unless these fragments remain in the pectoral muscle(6). As a preventive measure the use of hook wires close to the pectoral muscle should be avoided,the guide should be long enough not to remain submerged in the breast after initial decompressionand the outer end has to be securely fixed. Appropriate surgical technique must be used, avoidingcutting the hook wire (leaving the needle along with the hook wire already anchored may be of use)(7). The radiologist must always check for the presence of hook wire in the surgical specimen (6).

Cases have also been reported of metal particles similar to those of hook wires located aftercarrying out biopsies with hook wires, but their ethiology is uncertain (8).

Pacemakers in subpectoral locations may be superimposed over the pectoral muscle in the MLOprojection (Fig. 6, page 146). In some patients microcalcifications have been seen in the cavity left bythe pacemaker after removing this.

The Dacron sheath of Hickman catheters (used for administering antibiotics or chemotherapy bycentral catheterisation) is used for anchoring the catheter to the subcutaneous tissue. This cuff maybe left after removing the catheter, proving to be palpable and showing up in the mammography (4)(Fig. 7, page 146).

In the event of foreign bodies suspected of being gauze, drains, or fragments of needles beingseen (Fig. 2, page 144), the surgical case history must be investigated (5).

Mammary prostheses and reduction surgery.An increasingly large number of women are resorting to prostheses, both for postmastectomy

reconstruction, and for purely aesthetic purposes. Certain types of prosthesis may represent anobstacle for early breast cancer diagnosis, as their opacity may conceal lesions.

Until 1950 the injection of paraffin was used and in 1959 polyvinyl alcohol sponges started to beimplanted. From 1950 to 1960 the technique used was silicone injection (Fig. 8, page 147). From1962 silicone prostheses were implanted. In 1976, the FDA established the need for control, and in1991 it determined the hazards and relation with immune and collagen diseases. In 1992 the FDAaccepted prostheses under strict clinical control.

There are the following kinds of prostheses:

CASING CONTENTSilicone SiliconePolyurethane and silicone Silicone (this prosthesis is currently not used due to the

polyurethane)Silicone Physiological serumSilicone Combinations of silicone serum or inverse. This prosthesis

generally has two bags: silicone gel outside andphysiological serum inside, with a small valve used for fillingthe prosthesis with serum. This valve showed up in themammography in some cases.

Silicone Soya oil (Triglyceride). This prosthesis was withdrawn in1999 by the European Union Health Vigilance System,with the explantation of these being ordered throughproblems connected with the degradation of the oils.

Silicone HydrogelSilicone Silicone with cohesive gel and items.

The prostheses which contain silicone are the most opaque; the ones with serum have anintermediate opacity and the ones with triglycerides are the most radiotransparent, (reference hasalready been made to the order for withdrawing these.)

45

Prostheses generally have a variable and not very long lifetime, from 5 to 15 years approximately,which is why their control is recommended. The average life of prostheses is gradually lengthening asthe technology and the characteristics of implants progress.

Prostheses are classified, depending on their location as:- Submuscular: fitted under the pectoral muscle (Fig. 9 a and b, pages 147 and 148).- Subglandular: fitted under the gland and in front of the pectoral muscle, also known as

intramammary prostheses (Fig. 10 a and b, pages 148 and 149).- Subcutaneous: fitted under the skin.The problems that may be found in breasts containing prostheses are:- Capsular rupture with loss of the content and volume (Fig. 11, page 149).- Rupture of the prosthesis, without migration of the cohesive gel.- Exudation of the content with an intact capsule.- Contraction of the fibrous capsule.- Immune affections and collagen diseases (systemic lupus erythematous, schlerodermia, Sjöegren’s

syndrome, rheumatoid arthritis, inflammatory polyarthritis, polymyositis, dermatomyositis...) thoughthese are not very common.

- The risk of induction of breast cancer has been mentioned in some publications without anythorough studies having been made on this matter.

- Difficulty in early diagnosis. Breast prostheses interfere in the early diagnosis of breast cancerthrough their opacity, which makes it difficult to display the full mammary parenchyma. One musttake into account that submuscular-located prostheses and the most radiotransparent sorts are theones which poses fewest problems for mammographic diagnosis, which is why these are the mostrecommendable ones from the radiological standpoint. The prostheses which mean a greatesthindrance for reading are the silicone subglandular and subcutaneous implants.

The projections recommended in breasts with prostheses are:- Medio-lateral-oblique with free technique (without using the automatic exposure).- Craniocaudal, drawing the prosthesis back (Eklund’s manoeuvre) (Figs. 9 b and 10 b, pages

148 and 149).If the prosthesis constitutes a total impediment for mammographic reading, and if there is grounded

clinical suspicion, significant family risk or the patient suffers from cancerophobia, other diagnosticimaging methods can be used such as Magnetic Resonance with contrast.

Reductive mammary surgery can be recommendable in problems connected with large mammaryvolume, such as: posture problems, cervical and dorsal vertebral pathology, painful processes of thechest wall and breasts, exaggerated respiratory effort, which may induce pulmonary involvement,intertrigo in inframammary creases, mammary asymmetry, psychological problems etc..

Several surgical techniques have been described, but these basically consist in drying out mammarytissue and skin, and displacing the aureole-nipple complex. An incision can be made in the form ofan inverted T with a vertical part from the nipple downwards and horizontal line which goes rightalong the inframammary crease. An L from the aureole to the submammary sulcus and outer lateralor a vertical I incision from the aureole to the sulcus. In the mammography, an MLO projection willreveal downward displacement of the mammary tissue with a ring-shaped or twisted formation, aswell as tilting or elevation of the nipple, and dermal thickening in the vertical incision between thenipple and the inframammary crease. In CC and MLO projection dense bands resulting from fibrosiscan be seen in retroareolar projection, as well as redistribution and atypical or focal asymmetries ofthe mammary tissue. There may also be thickening of the skin coinciding with the incision linespreviosly described (Fig. 12 a and b, page 150), (9).

In the case of gigantomasty, aesthetic amputation of a large amount of mammary tissue is madewith free grafting of aureole-nipple, with the mammographic reading proving simpler through therebeing less structural alteration and reduced displacement.

Seldom-found tumoursThis category includes sarcomas, lymphomas and metastases.

“MISCELLANEOUS”

46

SarcomasThese are malignant tumours originating in the mammary stroma. These are rare, constituting

under 1% of all the malignant tumours of the breast. They appear from 45 to 55 years of age. Theyinclude highly differentiated forms such as fibro, angio and liposarcomas, or sarcomas of highlyimmature cells in which cartilaginous or osseous tissue can be found (Fig. 13, page 151).

These are clinically seen as large masses with fast growth in size of the breast, almost mimickinginflammatory processes, and with distortion of the mammary contour (10). These are mobile andnon-adhered masses.

Mammographically they look like large well-defined and dense rounded or lobulated nodules (11).They metastasise through the blood, generally to the lungs.

Angiosarcoma is differentiated through its different clinical and radiological characteristics. This isa very rare malignant lesion (0.04% of all malignant breast tumours). It has a very bad prognosis. Itmay appear at any age though it is more commonly found in young women. It may also appear afterradiotherapy. Bilateral disease tends to be associated with pregnancy. The clinical signs are unspecific,such as a painless mass or diffuse mammary increase. The most specific sign, which is the violet redor blue colouring of the adjacent skin, only occurs in 17-35% of cases.

In mammographies the findings are variable, and it may be seen as a mass with poorly defined orlobulated contours, and microcalcifications and spiculations are not associated with this. The 35%may have a negative mammography. Because of its great vascularisation there may be a haemorrhageafter biopsy. They tend to involve fast metastatic dissemination (12).

Phyllodes TumourA potentially malignant tumour which is differentiated from sarcomas through containing epithelial

tissue structures. It represents under 1% of mammary tumours.The great proliferation of its epithelial elements and of the stroma produces elongation and distortion

of the ducts, which gives rise to clefts or cystic cracks inside the tumour. These appear from 30 to 50years of age. Most of these lesions are benign, but differentiation between benignity and malignancyis only possible by means of a histological study, by valuing mytotic activity, cellular atypia, cellularity,growth of the stroma and characteristics of the edges (2, 13).

These tumours can be locally invasive and recur if not properly extirpated, the recurrences sometimesbeing more aggressive than the original tumour. If this metastasises the process is haematogenic andnot by the lymphatic channel. The metastasis of the phyllodes tumour acts in the same way assarcomas.

This is seen as a quickly growing mass, with smooth or lobulated edges and with certain mobility.In mammography they are indistinguishable from other well-defined mammary lesions, do not havespiculations nor microcalcifications, and are distinguished by their large size (Fig. 14, page 151).With ultrasound it is identical to fibroadenomas, well defined. Sometimes cystic zones can be seen.

The most advisable treatment is extensive excision and a mastectomy must be performed if thereis any recurrence.

LymphomaPrimary breast lymphoma is very rare, 0.1-0.5%. Secondary affectation is more common and the

distinction between these is based on the fact that for diagnosis the primary form requires normalmammary tissue around a focus of lymphoma in a patient with no other evidence of systemic affectationthrough this process (11).

Under examination this may be found as a palpable not painful mass.Mammographic findings of the lymphoma are not specific and furthermore there is no radiological

sign which distinguishes the primary lymphoma from the secondary one (11). The most commonfinding is the presence of a nodule or mass and, less frequently, several masses or nodules, notcalcified, with a circumscribed, oval or lobulated contour, or even poorly defined, and almost neverspiculated (14) (Fig. 15 a, b and c, pages 152 and 153).

Less frequently, these have been described as density asymmetries in combination with thickeningof the skin. If there are also large axillary or thoracic adenopathies one must always discard the

47

possibility of the generalised lymphoma (2), and there may be lymphoedema and an interstitialpattern with thickening of the skin through obstruction of the lymphatic drainage (11).

This is generally unilateral, though it can be bilateral. With ultrasound it seen as a highly vascularisedunspecific hypoechoic mass (15).

MetastasisIn mammography most of the metastatic lesions mimic benign nodes like cysts or fibroadenomas.

Metastases in breasts are single in 85% of cases, unilateral in 75%, and with a predilection for UOQ.Excluding metastases of contralateral breast carcinomas and of the lymphoma group, most of themetastases stem from melanoma, bronchial carcinoma, carcinoma of the ovary, kidney and softtissue sarcomas. (16,17).

These appear in mammography as one or more well-defined, rounded (Fig. 16, page 153), orlobulated nodes with fast growth between sequential mammographies.

These must also be suspected when one finds a well-defined nodule, localised in the subcutaneousfat and not in the mammary gland itself, or when its location is unusual or eccentric. Metastaticlesions are not usually accompanied by changes in the skin or spicula through the lack of a desmoplasticreaction (18). Very seldom these go with microcalcifications (such as with metastases or carcinoma ofthe ovary, or of medullary thyroid carcinoma) (17). Cytology is useful for differentiating metastasesfrom primitive breast carcinoma.

All the mammary tumoral lesions described in this chapter require a definitive histological diagno-sis.

Bibliography

1. Shaw de Paredes E. Atlas de Mamografia. Madrid: Ed. Marban 1994.2. Kopans DB. Alteraciones focales en la mamografía. In: La mama en imagen. Madrid: Ed. Marban 1994.3. Thomas DR, Fisher MS, Caroline DF. Case report: Soap, another artefact that can mimic intramammary

calcifications. Clinical Radiology 1995; 50: 64-66.4. Cardenosa G, Ecklund GW. Breast calcifications. In: Taveras JM y Ferrucci JT eds. Radiology Diagnosis

Imaging Intervention. Philadelphia: J.B. Lippincott Company 1994.5. Iribar M, Vilarrasa A. Alteraciones Radiológicas de la mama tratada. In: Monografías de Diagnostico por

Imagen 1992; 1: 101-125.6. Montrey JS, Levy JA, Brenner RJ. Wire fragments after needle localization. AJR 1996; 167: 1267-

1269.7. Homer MJ. Needle localization: Pitfalls. In: Mammographic interpretation. A Practical approach. New

York. Mc Graw-Hill Inc. 1997.8. Korbin CD, Denison CM, Lester S. Metallic particles on mammography after wire localization. AJR

1997; 169: 1637-1639.9. Cardenosa G, Eklund GW. Imaging the altered breast. In: Taveras JM y Ferrucci JT eds. Radiology Diag-

nosis Imaging Intervention. Philadelphia: J.B.Lippincott Company 1994.10. Cotran RS, Kumar V, Robbins SL. The Breast in: Robbins´s Pathologic Basis of Disease. Philadelphia.

W.B.Saunders Company. 1989; 1181-1201.11. D’Orsi CJ, Feldhaus L, Sonnenfeld M. Unusual lesions of the breast. The Radiol. Clin. of North Am.

1983; 67-69.12. Marchant LK, Orel SG, Perez-Jaffe LA, Reynolds C, Schnall MD. Bilateral angiosarcoma of the breast on

MR Imaging. AJR 1997; 169: 1009-1010.13. Liberman L, Bonaccio E, Hamele-Berna D, Abramson AF, Cohen MA, Dershawd DD. Benign and malignant

phyllodes tumors: Mammographic and sonographic findings. Radiology 1996; 198: 121-124.14. Pameijer FA, Beijerinck D, Hoogenboom HHVM, Deuremberg JJM, Nortier JWR. Non Hodgkin’s

Lymphoma of the breast causing miliary densities on mammography. AJR 1995; 164: 609-610.15. Kizitelpe TT. Breast metastasis from non Hodgkin’s lymphoma: evaluation with color Doppler sonography

(letter) AJR 1996; 167: 1595-1596.16. Hiorns MP, Murfitt J. Granulocytic Sarcoma (Chloroma) of the breast: sonographic findings. AJR 1997;

169: 1639-1640.

“MISCELLANEOUS”

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17. Soo MS, Williford ME, Elenberger CD. Medullary thyroid carcinoma metastatic to the breast: mammographicappearance. AJR 1995; 165: 65-66.

18. Belton AL, Stull MA, Grant T, Shepard MH. Mammographic and sonographic findings in metastatictransitional cell carcinoma of the breast. AJR 1997; 168: 511-512.

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APPENDIX I

DIAGNOSTIC PROTOCOL

MAMMOGRAPHY: MAMMOGRAPHIC CATEGORIES AND IMAGE DESCRIPTIONSMammography is the imaging technique normally used to detect a clinically occult breast carcino-

ma. Roughly 80-85% of all breast cancers can only be detected by mammography. Physicalexamination can detect 18-25% of breast cancers. A combination of physical examination andmammography can improve detection up to 90-95%. The remaining 5% of cases not detected aremade up of diffuse, infiltrating lesions which do not form a mass. Physical examination andmammography must be correlated since a carcinoma can be concealed by a dense glandular tissue inthe mammography. A palpable mass in a patient with a negative mammography must therefore beinvestigated by ultrasound and a cytological or histological study.

The pattern for action in our screening programme is as follows:A bilateral mammography is made in a dual projection (craniocaudal and medio-lateral-oblique) in

the first round and single projection (medio-lateral-oblique) in successive rounds.A double reading is performed: a first reading by the physician or radiologist at the facility and a

second independent reading by the reference radiologist. Both are blind, and in the event of anydisagreement a consensus between readers must be established.

The results of the mammography reading are classified in the following categories:

1. - NORMAL:1.1. - NORMAL FATTY.1.2. - NORMAL DENSE.

2. - BENIGN.3. - PROBABLY BENIGN.4. - PROBABLY MALIGNANT.5. - MALIGNANT.

CATEGORIES: Categories constitute each of the concepts or hierarchies which areestablished from normality to breast cancer.

At present we have discarded Category 1 NOT PERFORMED, through not meeting the definitionof mammographic category. BIRADS Category 0 requires further assessment, and is not used by ourreaders as an initial category but is instead a procedure to be followed proposed during consensus. Inthe remaining Categories we have adopted the BIRADS numbering, maintaining the terms used inour program and changing the numbering, in order to make the numbers in both systems coincide.

Category 1, NEGATIVE, is known as NORMAL. We prefer to use the term “normal” whenwe refer to a mammography reading which does not show any signs of pathology. We admit that anormal mammography does not mean a normal breast or the absence of cancer and only means a«lack of signs indicating pathology», and both concepts are thus equivalent.

50

Only this category adds the constitution of the breast. The BIRADS system putsforward four types of breast and justifies this system based on the sensitivity of themammography in each kind of breast, but without quantifying this sensitivity. Bysimplifying this application two types of breast will be allowed, the highly sensitivesort, which we call NORMAL FATTY, and the type that can conceal some type ofcancer behind the fibroglandular tissue, which is known as NORMAL DENSE.

Category 2 BENIGN FINDING in the BIRADS is known as BENIGN and in both systems itincludes the same lesions, with the exception of the intramammary lymph node of normal morphology,size and density, which we include as an anatomical variant in the Normal Category. The lesionsincluded in this category are detailed in the corresponding chapters as well as the procedure tofollow. The classification section of this chapter includes a list of these lesions.

Category 3 The BIRADS PROBABLY BENIGN FINDING is called PROBABLY BENIGN andincludes the same lesions. The lesions included in this category are detailed in the correspondingchapters as well as the procedure to follow. The classification section of this chapter includes a list ofthese lesions.

Category 4 The BIRADS SUSPICIOUS ANOMALY is called PROBABLY MALIGNANT andincludes the same lesions. The lesions included in this category are detailed in the correspondingchapters as well as the procedure to follow. The classification section of this chapter includes a list ofthese lesions.

Category 5 HIGHLY SUGGESTIVE OF MALIGNANCY in the BIRADS system is known asMALIGNANT and includes the same lesions. The lesions included in this category are detailed in thecorresponding chapters as well as the procedure to follow. The classification section of this chapterincludes a list of these lesions.

LOCATIONIn the Checklist used by the first and second mammography reader, we have implemented a

scheme for locating the lesions in the breast. The scheme represents the two radiographic projections,CC and MLO, and indicates the laterality, right or left-hand side and also the upper and lowerreferences for MLO projections and internal and external references for CC projections. One shouldremember that the lesion marked on the radiographic projection scheme may require translation tothe anatomical situation.

DESCRIPTION:The description of the mammographic reading involves some differences and finer distinctions

now explained:

Masses. We add the nodule. NODULE/MASS. These are lesions occupying space which can beseen in two projections.

The nodule is concrete, small in size and can be individually distinguished from everythingsurrounding it. The mass is large in size. The size limit for considering a lesion as being a nodule ormass can arbitrarily be established as 2 cm (Maximum diameter of the T-1).

We accept the BIRADS definition referring to three-dimensionality in two projections and also thestudy system for masses proposed for classification in the final categories.

We exclude the term “density” for not meeting the definition of mass through being two-dimen-sional and through having located this in the asymmetrical density section as “ASYMMETRY”.

We include the intramammary lymph node through complying with the definition of node andwhen its morphology and size are normal we classify this in the normal category, through consideringthis to be a normal anatomical variant.

Lymph nodes whose size, density, morphology or surroundings suggest adenopathies are includedin the probably malignant and malignant categories.

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We also include the skin lesions which produce a nodular image in the mammography, such asthe naevus and warts, not considering these as being breast pathologies.

Distortion of architecture. We use the same definition and classification proposed in the BIRADS.STRUCTURAL ALTERATION. Alteration of the structure or harmonic distribution of the partsforming a body. This mainly refers to fibrillar elements.

One form of structural alteration is the star. This name is used through its similarity with a star-shape. It consists in a radial image which converges on some point other than the nipple. We includetrabecular thickening, which in the BIRADS system is classified as an associated finding.

Calcifications. We use a definition and classification similar to that of BIRADS: CALCIFICATIONS.A transformation undergone by tissue through calcium salts being deposited on these. These depositsare visible and identifiable in mammographies, even being of minimum size, measurable in micras.

We consider some calcifications such as vascular, dermic and cicatricial as being normal.

ASYMMETRY: Asymmetry is the lack of symmetry. We consider symmetry to be a harmony ofposition between similar parts or points, in respect of each other and with regard to a particularpoint, line or plane. This basically refers to fibroglandular tissue.

By following this concept we value the symmetry of radiological density by placing the projectionsof the breasts so that one is the mirror image of the other, and we analyse the distribution of densitiesin each projection comparing both breasts.

Special cases. Of the four cases indicated in the BIRADS as special cases, one of these -“Intramammary lymph node” - has been moved to the “NODULE / MASS” section, throughconsidering that it complies with the definition of this. The other three: “Tubular density or isolateddilated duct”, “Asymmetric mammary tissue” and “Focal asymmetric density”, have in common thefact that these are radiological densities and are also symmetrical. We think that these three conceptscan be included in a common section which we call “ASYMMETRICAL DENSITY”, or simplyASYMMETRY, which from a descriptive standpoint is more specific than the “special cases” usedin the BIRADS system, which means the type of case being referred to has to be specified. Of thethree cases, density in fibroglandular tissue will be considered as being normal or benign, tubulardensity as probably benign and focal density as suggestive of malignancy.

Associated findings. These are considered to be an extremely heterogeneous series of signs whichcan either be found isolated or in combination with other signs. Their heterogeneity makes it difficultto classify them in groups, which is why we opted for seeking a solution to allow them to be collectedas information, in the same way as the previous section. To do this we will divide this group intoseveral groups: ALTERATIONS OF THE SKIN/NIPPLE. Altering means changing the essenceor form of something. We analyse above all the change in the thickness of the skin and the nipple,comparatively studied, as well as any retraction, sinking or alteration in its surroundings. It groups thedescriptions of the BIRADS and can be found as a single or associated lesion.

COMBINED/MULTIPLE: This indicates that the lesions described above are associated throughconstituting the lesion which gives rise to the main category. It excludes adenopathy, which shouldbe included in the nodule /mass section. It includes the distortion of architecture, calcifications,alterations of the skin and nipple and multiple instances of the lesions described in the same category.It should not be used to relate different categories.

OTHERS: This refers to lesions or images of a lower category whose presence the reader wishesto inform of or record, although the type of image is not described.

MISCELLANEOUS: This includes artefacts, foreign bodies and implants or infrequent tumoursof known diagnosis.

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For the classification of mammographic studies in categories we use a reading system based onthe description of images which includes the following terms that have been defined and endorsed:

1. NODULE / MASS2. STRUCTURAL ALTERATION3. CALCIFICATION4. ASYMMETRY5. ALTERATIONS OF THE SKIN / NIPPLE6. COMBINED / MULTIPLE7. OTHERS8. MISCELLANEOUS

REMARKSThe reader wishes to express, in the form of free text, any observations which are not

mentioned in the reading system and which may refer to technical data or notes for specifyingsome detail of the reading.

PROCEDURE TO BE IMPLEMENTED Just as these categories are equivalent to the ones used by the BIRADS system, so is the

approach or PROCEDURE TO BE IMPLEMENTED.

The approach or procedure to be implemented is determined after performing the double readingand consensus at our facilities. The physical examination and further projections are made at thescreening facilities, by the physician or radiologist of the facility, though there is no possibility ofperforming ultrasounds as this technique is not available at the facilities.

The procedure to be implemented considers the following cases:

1) NORMAL FOLLOW-UP. In two years in our screening programme. Made with women fromthe normal and benign categories.

2) SHORT-TERM FOLLOW-UP. In our programme, since the time elapsing between checkupsis two years, the short-term follow-up is given at six and twelve months.

This is for women with particular lesions in the probably benign category.3) SENDING ON TO HOSPITAL. This is applied to women for whom the study must be

completed for obtaining the final diagnosis and who require ultrasound or some type of interventiontest for cytological or histological diagnosis. This is implemented with women with certain probablybenign lesions, and women who were included in the probably malignant and malignant categories.

ULTRASOUNDUltrasound is used for differentiating the solid or liquid nature of a mammary nodule. It does not

distinguish benignity from malignancy and neither does it detect microcalcifications, meaning thatultrasound is no use for carrying out screening in a programme for prevention ofbreast cancer.

Ultrasound will be used as follows in the Programme:- For differentiating the solid or cystic nature of a nodule.- For assessing a palpable mass in a dense breast or within an asymmetric density.- For valuing masses or nodules whose location means that they might not have been included in

the mammography.- Ultrasound is a useful method in interventionist procedures, for guiding needles in FNAB and

also in obtaining cores with core needles. It can watch over total evacuation of a cyst, and isuseful for placing signals with hookwires in lesions which are easily visible in ultrasound.

When there is a palpable mass which cannot be shown to be cystic in the ultrasound, this must beconsidered to be solid, proceeding to a cytological or histological study of this.

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CLASSIFICATIONS

CATEGORIES

1. Normal1.1. Normal fatty1.2. Normal dense

2. Benign3. Probably benign4. Probably malignant5. Malignant

TYPE OF MAMMOGRAPHIC IMAGEDescription of the lesion

1. NORMAL1.1. Nodules

1.1.1. Lymph node.1.1.2. Lesions in the skin (warts, sebaceous cyst...).

1.2. Structural alteration1.2.1. Pseudostar produced by superimposing the normal structures of the breast.

1.3. Calcifications1.3.1. Vascular calcification.1.3.2. Microcystic calcifications.1.3.3. Dermic calcifications.1.3.4. Cicatricial calcifications.

1.4. Asymmetries1.4.1. Vascular.1.4.2. Of volume.1.4.3. Of fibroglandular tissue (retroareolar or in UOQ, with fat, not volumetric, visible in a

single projection).1.5. Alterations of the skin/nipple

1.5.1. Scar.

2. BENIGN2.1. Nodule/Mass

2.1.1. Nodules of water density2.1.1.1. Sharp nodule of 5-10 mm in size, well-defined contour and low density, transparent.2.1.1.2. Nodules considered benign after ultrasound, follow-up, review of previous studies

or cytological or histological studies.2.1.2. Nodules with fatty density

2.1.2.1. Hamartoma2.1.2.2. Lipoma2.1.2.3. Galactocele2.1.2.4. Oily cyst

2.2. Structural alteration2.2.1. Structural alteration through traumatism2.2.2. Structural alteration through surgery2.2.3. Structural alteration through infection

2.3. Calcifications2.3.1. Calcification of fibroadenoma2.3.2. Macrocystic liponecrosis

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2.3.3. Granulomas of foreign bodies2.3.4. Ductal or periductal with sharp contour2.3.5. Calcium milk in cyst2.3.6. Disperse microcalcifications of benign morphology, homogeneous, unilateral or bilate-

ral, with a tendency to symmetrical distribution, and which do not form groups orpseudogroups.

2.4. Asymmetries2.4.1. Asymmetries of fibroglandular tissue secondary to traumatism, infection or surgery.2.4.2. Asymmetries of fibroglandular tissue considered as being benign after ultrasound, follow-

up, review of previous studies or cytological or histological study.2.5. Alterations of the skin/nipple

2.5.1. Localised thickening of the skin.2.5.1.1. Infection2.5.1.2. Traumatism2.5.1.3. Surgery

2.5.2. Diffuse thickening of the skin, associated with generalised oedema through mastitis,heart or kidney disease.

2.6. Combined, multiple: Includes all the possible combinations of benign findings, or the unilate-ral or bilateral simultaneous presentation of benign, isolated or combined findings. A frequentfinding of benign combined lesion is the nodule with signs of benignity and calcificationswhose morphology means these are typical of fibrodenoma.

2.7. Others: Includes any finding in the normal category, which is found simultaneously with thebenign findings.

3. PROBABLY BENIGN:3.1. Nodule/mass: Sharp nodule of smooth contour, well-defined, round, elliptical or discretely

lobulated without calcification.3.2. Calcifications: Microcalcifications, grouped, round, oval or spherical, homogeneous with a

sharp contour, small, amorphous, in corn-flakes or blurred.3.3. Asymmetry: of fibroglandular tissue, with volume effect, visible in two projections, located in

areas other than the areolar or upper-outer regions.3.3.1. Asymmetry of the parenchyma.3.3.2. Ductal asymmetry.

3.4. Combined/multiple: Includes all the possible combinations of probably benign findings, orthe simultaneous unilateral or bilateral probably benign, isolated or combined findings.

3.5. Others: Includes any finding in the normal or benign category found simultaneously withprobably benign findings.(1)

4. PROBABLY MALIGNANT:4.1. Nodules: with poorly defined contour, spiculated, irregular, polylobulated or microlobulated

or with an extension in comet-tail form.4.2. Structural alteration

4.2.1. Stars.4.2.2. Structural alteration of the architecture of the breast without associated mass.

4.3. Calcifications: Microcalcifications with characteristics of malignancy, either grouped or inregional or segmentary distribution, heterogeneous in shape, size and density, intraductal,vermiform, granular, with irregular poorly defined contours.

4.4. Asymmetry: Tumoral, with mass effect, associated with structural alteration or with malignanttype microcalcifications.

55

4.5. Combined/multiple: In this section one can include unilateral or bilateral presentation ofisolated probably malignant findings.

4.6. Others: Includes any finding in the normal, benign or probably benign category which isappreciated simultaneously with probably malignant findings.(2)

5. MALIGNANT5.1. Nodule/Mass: with spiculated, irregular, polylobulated or poorly defined contour associated

with malignant microcalcifications, retraction of the skin or the nipple, or retraction of thepectoral muscle.

5.2. Tumoral structural alteration: associated with malignant microcalcifications, thickening andretraction of the skin or the nipple.

5.3. Tumoral asymmetry: associated with structural alteration, malignant microcalcifications,thickening and retraction of the skin or the nipple.

5.4. Skin/nipple alterations: Includes items of clinical-radiological diagnosis.5.4.1. Inflammatory carcinoma: Peau d’orange, inflammatory signs, associated with tumor or

tumoral asymmetry, malignant microcalcifications, structural alterations and axillaryadenopathies.

5.4.2. Paget’s disease: Eczema of the nipple, either isolated or associated with a nodule, massor malignant tumoral asymmetry, or with malignant microcalcifications.

5.5. Combined/multiple: These lesions are combinations of probably malignant lesions, with orwithout alterations of the skin, nipple, retraction of the pectoral muscle and on occasionswith axillary adenopathies. Malignant lesions can be multiple, unilateral or bilateral.

5.6. Others: Includes any finding in the normal, benign or probably benign category, foundsimultaneously with malignant findings.(3)

8. MISCELLANEOUS8.1. Artefacts8.2. Superimpositions8.3. Foreign bodies8.4. Mammary implants8.5. Reductive surgery8.6. Cystosarcoma phyllodes8.7. Sarcomas8.8. Linfomas8.9. Metastasis originating outside the breast

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

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

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

57

APPENDIX II

WORKSHEET

59

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

NAME: ................................................................................................................................

DATE:.........................................

LOCATION OF LESION

RB LB RB LB

UPPER OUTER

MLO CC

MAMMOGRAPHIC FINDINGSLB RB

1. Nodule / Mass (Masses) 1 12. Structural Alteration (Architectual distortion) 2 23. Calcifications (Calcifications) 3 34. Assymetry (Asymmetry of density)* 4 45. Skin/Nipple Alterations (Skin and nipple alterations) 5 56. Combined/Multiple (Associated findings and multiple lesions)** 6 67. Others (non-significant additional lesions) 7 78. Miscellaneous*** 8 8

ASSESSMENT CATEGORIESLB RB

1. Normal (Negative): 1 11.1. Fatty (Fat breast) 1. 1.

1 11.2. Dense (Dense breast) 1. 1.

2 22. Benign (Benign finding) 2 23. Probably benign (Probably benign finding) 3 34. Probably malignant (Suspicious abnormality) 4 45. Malignant (Highly suggestive of malignancy) 5 5

* Includes density assymetry and assymetric ductal pattern. As special cases in BIRADS System, includes solitary dilated duct, asymmetricbreast tissue and focal asymmetric density.

** Used for describing a combination of findings or when these are multiple. As associated findings in BIRADS system.

*** Includes artefacts, implants and foreign bodies.

REMARKS:........................................................................................................................................................................................................................................................................................

PROCEDURE TO BE IMPLEMENTED............................................................................................................................................

61

NORMAL

63


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

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

64


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

Fig. 3. Intramammary lymph nodewith hilum notch and radiolucentcentre (arrow)

65


Fig. 4. Large-sized axillary lymphnodes with fatty centre.

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

66


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

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

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

67


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

68


Fig. 10a. Sebaceous cyst.

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

69


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

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

70


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

Fig. 12.Vascular calcification.

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

71


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

72


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

Fig. 16. Microcystic calcifications. Magnified projection.

73


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

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

74


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

75

BENIGN

77


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

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

78


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

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

79


Fig. 4. Ultrasound findings in a probably

benign nodule with solidcharacteristics.

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

80


Fig. 6. Small nodule characteristicallybenign.

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

81


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

Fig. 8b. Lipoma with compression of thesurrounding parenchyma in a dense breast.

82


Fig. 9. Galactocele. Fluid-level of waterand fat densities.

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

83


Fig. 12a. Calcified fibroadenoma in a fattybreast.

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

84


Fig. 12b. Calcified fibroadenoma in adense breast.

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

85


Fig. 15. Ductal calcifications in plasmacells mastitis.

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

86


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

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

87


Fig. 17. Diffuse benign bilateralmicrocalcifications.

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

88


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

Fig. 19a. Postsurgical asymmetry with mass effect.

89


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

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

90


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

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

91


Fig. 22. Fibroadenoma with typical calcifications.

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

92


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

93

PROBABLYBENIGN

95


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

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

96


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

Fig. 2b. Ultrasound shows a solid, anechoic lesion with acoustic absorption

and calcification. The cytological diagnosiswas non-specific granuloma. No changes

were detected in the follow-up (two years)

97


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

Fig. 4. Ultrasound imaging of a intracystic papilloma.

98


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

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

99


Fig. 7. Group of heterogeneous, amorphous and well defined calcifications, coarse elements withhomogeneous density, the particle size was more than 1 mm. The cytology result was benign. Nochanges were observed in follow-up (three years)

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

100


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

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

101


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

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

102


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

Fig. 11a. Asymmetric ductal pattern.

103


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

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

104


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

Fig. 13. Diffuse bilateral calcifications.

105


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

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

106


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

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

107


Fig. 16b. Ultrasound shows indeterminatefindings (not definitively solid or liquidlesion)

Fig. 16c. Stereotaxic pneumocystography shows the incomplete filling of lesion. The aspirate wasbloody and the cytological diagnosis was positive to malignant cells. The histological diagnosis was a3 mm intracystic ductal carcinoma “in situ”.

108


Fig. 17b. The ultrasound found a massunseen in the asymmetric density. Thecytological diagnosis was positive formalignant cells. The histological diagnosiswas an IDC (10 mm.-size)

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

109

PROBABLYMALIGNANT

110

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

111


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

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

112


Fig. 2. Mass with irregular contour.

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

113


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

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

114


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

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

115


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

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

116


Fig. 7b. Small spiculated mass. Magnifiedprojection.

Fig. 8. Mass with irregular and indistinctcontour.

117


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

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

118


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

119


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

Fig. 11b. Small ill-defined low densitymass. The magnification view shows themargins of tumour up better.

120


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

Fig. 13. Star lesion.

121


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

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

122


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

Fig. 15b. CC projection (arrows)

123


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

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

124


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

Fig. 17. Probably malignant microcalcifications.

125


Fig. 19. Heterogeneous group of microcalcifications.

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

126


Fig. 20. Innumerable granular microcalcifications.

Fig. 21. Casting microcalcifications withsegmental distribution (arrows)

127


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

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

128


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

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

129


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

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

130


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

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

MALIGNANT

131

132

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

CATEGORY 5. “MALIGNANT ”

133

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

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


134

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

Fig. 4.Spiculated mass with casting microcalcifications.


135

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

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


136

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

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


137

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

Fig. 9 a. Inflammatory carcinoma.Skin, nipple and trabecular thicke-ning. MLO projection.


138

Fig. 9 b. CC Projection.

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


139

Photo 1. Inflammatory carcinoma.

Photo 2. Eczema of the nipple in Paget’s carcinoma.

141

MISCELLANEOUS

143

MISCELLANEOUS

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

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

144

MISCELLANEOUS

Fig. 2. Foreign body: fragment of surgicalneedle.

Fig. 3. Intramammary projectiles: shotgun pellets.

145

MISCELLANEOUS

Fig. 4. Calcifications of suture materialsin knot form.

Fig. 5. Fragments of a hook wire.

146

MISCELLANEOUS

Fig. 6. Pacemaker.

Fig. 7. Dacron sheath of Hickman catheters.

147

MISCELLANEOUS

Fig. 8. Silicone balls injected for aesthetic purposes.

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

148

MISCELLANEOUS

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

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

149

MISCELLANEOUS

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

Fig. 11. Empty implant after breakagewith loss of the content.

150

MISCELLANEOUS

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

Fig. 12b. CC projection.

151

MISCELLANEOUS

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

Fig. 14. Cystosarcomas phyllode.

152

MISCELLANEOUS

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

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

153

MISCELLANEOUS

Fig. 16. Multiple masses, metastasis froma uterine sarcoma.

Fig. 15c. Axillary adenopathies.

155

I N D E X

INDEX OF FIGURES

CHAPTER II . CATEGORY 1. “NORMAL”

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

CHAPTER III. CATEGORY 2. “BENIGN”

Fig. 1. Calcifications of plasma cells mastitis which could be considered both as normal orbenign finding ............................................................................................................................. 77Fig. 2. Probably benign nodule (1), simple cyst was confirmed by FNAB andpneumocystography (2). The classification will be “benign nodule” in future examinations. ................ 77Fig. 3a. The contour of a low density nodule is partially concealed due to superimposedfibroglandular tissue (arrows). Magnified projection ......................................................................... 78Fig. 3b. Ultrasound findings in a simple cyst .................................................................................. 78Fig. 4. Ultrasound findings in a probably benign nodule with solid characteristics .............................. 79Fig. 5. Two nodules (solid at ultrasound) with well-defined contour and diameter superior to 5 mm.The nodule in the left breast has benign calcifications (arrow) and must be considered definitivelybenign (fibroadenoma), and the nodule in the right breast must be classified as probably benignand followed-up .......................................................................................................................... 79Fig. 6. Small nodule characteristically benign ................................................................................. 80Fig. 7. Hamartoma. The nodule displayed a combination of water and fat densities surrounded by apseudocapsule ............................................................................................................................ 80Fig. 8a. Lipoma with a capsule in a fatty breast (arrows) ................................................................. 81Fig. 8b. Lipoma with compression of the surrounding parenchyma in a dense breast ........................ 81Fig. 9. Galactocele. Fluid-level of water and fat densities ................................................................ 82Fig. 10. Oil cyst after surgical biopsy (arrows) ................................................................................ 82Fig. 11. Structural alteration of the parenchyma (arrows) due to surgical resection ............................ 83Fig. 12a. Calcified fibroadenoma in a fatty breast ........................................................................... 83Fig. 12b. Calcified fibroadenoma in a dense breast ......................................................................... 84Fig. 13. Post-traumatic fat necrosis: bilateral calcificans macrocystic liponecrosis .............................. 84

156

I N D E X

Fig. 14. Calcified granulomas due to materials of surgical sutures (arrowheads) ................................. 85Fig. 15. Ductal calcifications in plasma cells mastitis ....................................................................... 85Fig. 16a. Milk of calcium in cyst: Craniocaudal projection, blurred contour of particles (arrows) .......... 86Fig. 16b. Milk of calcium in cyst: Lateral Projection: typical cup of tea shape (arrows) ....................... 86Fig. 17. Diffuse benign bilateral microcalcifications......................................................................... 87Fig. 18a. Fibroglandular asymmetry with stability in the two-year follow-up (93/95),MLO projection (arrowheads) ....................................................................................................... 87Fig. 18b. Fibroglandular asymmetry with stability in the two-year follow-up (93/95),CC projection (arrowheads) .......................................................................................................... 88Fig. 19a. Postsurgical asymmetry with mass effect ......................................................................... 88Fig. 19b. The ultrasound of lesion depicted in Figure 19a shows a hypoechoic mass.The histological diagnosis by core biopsy (14G, 3 cores) was granuloma of suture material ................ 89Fig. 20a. MLO projection, the surgical resection in the right breast simulates anasymmetry of density in the left breast (also, artefacts that mimic calcium and technical problem,underexposed view due to deficient compression in the right breast) ................................................ 89Fig. 20b. Postsurgical changes, CC projection showing retraction and thickening of skin ................... 90Fig. 21. Diffuse thickening of skin. Retroareolar abscess. ................................................................ 90Fig. 22. Fibroadenoma with typical calcifications............................................................................ 91Fig. 23. Multiple bilateral nodules, simple cysts by ultrasound .......................................................... 91Fig. 24. Calcified fibroadenoma, vascular calcifications and calcifications of microcystic liponecrosis ... 92

CHAPTER IV. CATEGORY 3. “PROBABLY BENIGN”

Fig. 1a. Nodule with well-defined contour ...................................................................................... 95Fig. 1b. The nodule shows solid characteristics in ultrasound. Malignancy was suspected fromcytology (false positive result). The histological diagnosis was fibroadenoma...................................... 95Fig. 2a. Nodule with partially visible contour. Another adjacent small nodule (arrow) .......................... 96Fig. 2b. Ultrasound shows a solid, anechoic lesion with acoustic absorption and calcification.The cytological diagnosis was non-specific granuloma. No changes were detected in thefollow-up (two years) .................................................................................................................... 96Fig. 3. Nodule with lobulate contour. The cytological diagnosis was fibroadenoma.No changes were detected in the follow-up (three years) ................................................................. 97Fig. 4. Ultrasound imaging of a intracystic papilloma ...................................................................... 97Fig. 5. Group of 8 microcalcifications with the same shape, size and density.No changes were detected in the follow-up (three years) ................................................................. 98Fig. 6. Round-shaped small microcalcifications distributed in one lobule of the breast,the elements had the same shape, but different size and density and outline multiple groupsof 4-6 particles. Despite this lesion being considered probably benign, women prefer thebiopsy and the histological result was calcifications in ductal and lobular atrophy. .............................. 98Fig. 7. Group of heterogeneous, amorphous and well defined calcifications, coarse elementswith homogeneous density, the particle size was more than 1 mm. The cytology result was benign.No changes were observed in follow-up (three years). ..................................................................... 99Fig. 8a. Group of coarse, amorphous and heterogeneous calcifications, with other elements oflower density and linear shape (arrows) ......................................................................................... 99Fig. 8b. An increase in particles was detected (arrows) in the 6-months follow-up.The histological diagnosis was calcifications in cysts, fibrosis and hyalinosis. ..................................... 100Fig. 9a. Normal mammogram prior to HRT (hormone replacement therapy) ................................... 100Fig. 9b. Asymmetry of density that was developed in a patient with HRT.The palpation and ultrasound were negative. No changes were seen in the subsequent follow-up ....... 101Fig. 10a. Palpable asymmetric density located in the lower-inner quadrant (arrowheads) .................... 101Fig. 10b. An hypoechoic mass was depicted by ultrasound. The cytology was positive formalignant cells and the histological diagnosis was IDC (invasive ductal carcinoma)-T2, N0 ................. 102Fig. 11a. Asymmetric ductal pattern ............................................................................................. 102Fig. 11b. The galactography shows dilated ducts with an intra-luminal filling defect.The histological diagnosis was intraductal papilloma ....................................................................... 103Fig. 12. Multiple bilateral nodules in a patient with HRT. Ultrasound shows simple cysts .................... 103Fig. 13. Diffuse bilateral calcifications ........................................................................................... 104

157

I N D E X

Fig. 14a. Elliptical and well-defined nodule, with a size of 9 mm (arrowhead) that wasconsidered probably benign and followed-up. ................................................................................. 104Fig. 14b. The nodule had grown (14 mm.) after six months.The histological diagnosis was IDC (arrow) .................................................................................... 105Fig. 15a. Group of microcalcifications with stability in two years (arrow) ........................................... 105Fig. 15b.The microcalcifications displayed changes three years later (arrow).The histological diagnosis was IDC. .............................................................................................. 106Fig. 16a. A 9 mm, round and lobulate nodule ................................................................................ 106Fig. 16b. Ultrasound shows indeterminate findings (not definitively solid or liquid lesion) .................... 107Fig. 16c. Stereotaxic pneumocystography shows the incomplete filling of lesion.The aspirate was bloody and the cytological diagnosis was positive to malignant cells.The histological diagnosis was a 3 mm intracystic ductal carcinoma “in situ” .................................... 108Fig. 17a. Non-palpable asymmetric density, visible only in the MLO projection................................. 108Fig. 17b. The ultrasound found a mass unseen in the asymmetric density.The cytological diagnosis was positive for malignant cells.The histological diagnosis was an IDC (10 mm.-size) ...................................................................... 108

CHAPTER V. CATEGORY 4. “PROBABLY MALIGNANT”

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

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

158

I N D E X

Fig. 23a. Focal asymmetric density. MLO projection (arrows) .......................................................... 127Fig. 23b. Focal asymmetric density with architectural distortion. CC projection (arrows) .................... 128Fig. 24. Large, high density, tumoral asymmetry ........................................................................... 128Fig. 25a. Non-palpable asymmetry. CC projection (arrows) ............................................................. 129Fig. 25b. Focal compression view, asymmetry with mass effect ....................................................... 129Fig. 25c. A hypoechoic mass was depicted by ultrasound ............................................................... 130Fig. 26. Small bilateral spiculated masses, bilateral carcinomas (arrows) ............................................ 130

CHAPTER VI. CATEGORY 5. “MALIGNANT”

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

Fig. 1. Spiculated tumour with retraction of the skin ....................................................................... 133Fig. 2. Spiculated tumour with casting microcalcifications and retraction of the pectoral muscle ......... 133Fig. 3. Spiculated tumour with retraction of the nipple ................................................................... 134Fig. 4. Spiculated mass with casting microcalcifications .................................................................. 134Fig. 5. Spiculated mass with heterogeneous microcalcifications and thickening andretraction of the skin ................................................................................................................... 135Fig. 6. Palpable tumoral density and architectural distortion with microcalcifications .......................... 135Fig. 7a. Asymmetrical tumoral density associated with palpable mass. MLO projection ...................... 136Fig. 7b. Diffuse asymmetric high density in the left breast. CC projection ......................................... 136Fig. 8. Inflammatory carcinoma. Heterogeneous microcalcifications with thickeningof the skin and nipple, associated with clinical signs (see colour photo 1, p. 139) .............................. 137Fig. 9a. Inflammatory carcinoma. Skin, nipple and trabecular thickening. MLO projection ................. 137Fig. 9b. CC Projection ................................................................................................................. 138Fig. 10. Retroareolar masses in a case with Paget disease (see colour photo 2, p.139) ...................... 138Photo 1. Inflammatory carcinoma ................................................................................................ 139Photo 2. Eczema of the nipple in Paget’s carcinoma ...................................................................... 139

CHAPTER VII. MISCELLANEOUS

Fig. 1. Artefacts that simulate calcifications produced by deodorant creams in the axilla ..................... 143Photo 1.Skin ulcers produced by the application of an abrasive substance ........................................ 143Fig. 2. Foreign body: fragment of surgical needle ........................................................................... 144Fig. 3. Intramammary projectiles: shotgun pellets ........................................................................... 144Fig. 4. Calcifications of suture materials in knot form ..................................................................... 145Fig. 5. Fragments of a hook wire .................................................................................................. 145Fig. 6. Pacemaker ....................................................................................................................... 146Fig. 7. Dacron sheath of Hickman catheters .................................................................................. 146Fig. 8. Silicone balls injected for aesthetic purposes ........................................................................ 147Fig. 9a. Submuscular implants. MLO projection showing the underlying muscle situation (arrows) ...... 147Fig. 9b. Submuscular implants. CC projection, the prosthesis has been displacedby Eklund’s handling.................................................................................................................... 148Fig. 10a. Subglandular implants. MLO projection showing the situation of the prosthesis .................. 148Fig. 10b. Subglandular implants. CC projection, the prosthesis has been displacedby Eklund’s handling.................................................................................................................... 149Fig. 11. Empty implant after breakage with loss of the content ........................................................ 149Fig. 12a. Reduction mammoplasty, with anomalous distribution of the fibroglandulartissue and pseudonodules. MLO projection .................................................................................... 150Fig. 12b. CC projection ............................................................................................................... 150Fig. 13. Osteosarcoma of the breast, solid bone matrix and osseous spiculations .............................. 151Fig. 14. Cystosarcomas phyllodes ................................................................................................. 151Fig. 15a. Lymphoma of the breast. The mammogram displayed a dense asymmetricalbreast tissue with mass effect ........................................................................................................ 152Fig. 15b. CT: Diffuse invasion of the parenchyma.......................................................................... 152Fig. 15c. Axillary adenopathies .................................................................................................... 153Fig. 16. Multiple masses, metastasis from a uterine sarcoma ........................................................... 153

159

I N D E X

INDEX OF TERMS

A

abscess, 26, 41accessory mammary tissue, 20adenosis, sclerosing adenosis, 34, 35, 40alteration, alterations, 17, 19, 20, 24-26, 30, 34, 35, 39, 41, 45, 51, 52

in benign category, 26in malignant category, 40in normal category, 20of skin/nipple, 20, 26, 40, 41, 51, 52

amorphous (see calcifications)anechoic (lesion in ultrasound), 23angiosarcoma, 46annular (see calcifications)antimitotic (cutaneous lesion by application of), 43areolar (subareolar), 19, 20, 24, 30, 39, 41, 45artefact, 43, 51

and superimposing, 43by tattooing, 43

assessment, 49asymmetric ductal pattern, 30asymmetry, 20, 25, 26, 30, 35, 36, 40, 45, 50, 51

asymptomatic, 20, 39, 43, 44characteristics of benignity, 29in benign category, 25in malignant category, 40in normal category, 20in probably benign category, 30in probably malignant category, 35isodense, 20of volume, 20tumoral, 35vascular, 20

axillary adenophaties (see lymph node)tail, 18

B

barium (as marker), 19barium sulphate (artefact by), 43benign pathology, 18benign, benignity, 11, 14, 17, 18, 20, 23, 46, 47, 49, 50-52bibliography, 15, 21, 27, 31, 37, 42, 47bilateral lesion (probably benign), 30

lymphoma, 46mammography, 49microcalcifications, 25, 30oedema, 19, 26, 40, 47

biopsy, 18, 20, 23, 24, 26, 29-31, 33-36, 41, 46directed by coordinates, 31directed by stereotaxy, 31, 36directed by ultrasound, 36

160

I N D E X

fine needle aspiration (see FNAB)with hook wire (harpoon), 36tumorectomy, 20

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

C

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

161

I N D E X

small, 35spherical, 25, 30tubular, 25vascular, 19with radiolucent centre, 19, 20

calcify, 19, 25, 43calcium (deposits of, salts of), 25, 35, 51calcium milk in cyst, 25calcium salts in hard waters (artefact by), 43capsule, 24, 45carcinoma medullary of the thyroids, 47

bronchial (metastasis of ), 47ductal, in situ (DISC), 35infiltrating ductal (IDC), 35inflammatory, 39-41lobular infiltrating, 35medullary, 34mucinous or colloid, 34of the ovary (metastasis of), 47papillary, 34

category 1, “Normal”, 172, “Benign”, 233, “Probably benign”, 294, “Probably malignant”, 335, “Malignant”, 39

CC (see craniocaudal)changes postinfectious, 25

postmenopausal, 19postoperative, 20, 21, 25, 26, 34, 35, 40post-traumatic, 24-26

cicatricial (see calcifications)sequels, 20

clinical examination, physical examination, 18, 24, 26, 29, 36, 39, 49coarse (see calcifications)collateral circulation (a form of asymmetry), 20combined /multiple, 26, 30, 36, 41, 51comet tail (sign of), 33, 34, 54complementary studies, 14, 23conduct generated by the benign category, 23

generated by the malignant category, 41generated by the probably benign category, 30generated by the probably malignant category, 36

contour (of a lesion) blurred, 33, 34, 46irregular, 33, 34microlobulated, 33, 34sharp, 24, 29spiculated, 33, 34, 39, 46

core needle biopsy, cylinder biopsy, 26, 29, 31, 33, 34, 36, 52craniocaudal projection (CC), 25, 40, 45, 49, 50creams, 19, 43cutaneous pore, 19cutaneous thickening, 21

ulceration (in advanced cancer), 41cyst, 19, 20, 23-26, 29, 46, 52

characteristics in ultrasound, 23epidermal, inclusion, 19sebaceous, 19

cytological, cytology, 14, 29, 31, 41, 47, 49, 52

162

I N D E X

D

dense breast, 17, 18, 25, 34, 35, 40, 52density, fat, 24

focal, 30high, 18homogeneous, 24, 25low, 18, 19, 24mixed, 17-19, 24tumoral asymmetry (see asymmetry)water, 24

deodorant (artefact by), 19, 43dermatomyositis (in relation to prostheses), 45dermic (see calcifications)

creams, 19lymphatics (infiltrating by), 41

desmoplastic reaction (see fibrosis, elastosis)diagnostic algorithm, 55dictionary of language, 14difficulty in early diagnosis due to the prostheses, 45dilated duct, in probably benign asymmetry, 30

in the Paget disease, 41disease, 40, 41, 44-46

metastatic, 41of the collagen (immune), 18, 44, 45

distortion of the architecture (see structural alteration)Dracon sheath (superimposing by), 44ductal (see calcifications, carcinoma)

E

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

F

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

cicatricial, 34

163

I N D E X

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

G

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

H

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

I

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

164

I N D E X

isodense (asymmetry), 20

L

lactation, 17, 24lesion/s, 18, 19, 23, 24, 26, 29-31, 33-36, 39-41, 43, 44

in the skin, 18intracystic, 29malignant, 36, 39, 41multiple, 30, 36non-palpable, 29, 36, 43

linear (see calcifications)lipoma, 14, 24liponecrosis, 20, 23, 25

calcified, 23cystic, 25

liposarcoma, 46lobulate, lobulations (in nodule), 29, 33, 34, 46, 47location of a lesion with hook wire, 36low density (lesion of), 18, 34low risk (in probably benign lesions), 29, 31lupus erythematosus (in relation to prosthesis), 45lymph node, 18, 43, 51

axillary, 18, 43echographic characteristics, 18intramammary, 18, 43, 50, 51

lymphatic obstruction, 41lymphoma, primary lymphoma, 18, 41, 45-47

M

magnetic resonance (in prostheses), 45mammographic atlas, 7, 14

report, 13report negative in breast cancer, 18

mammography, 13, 17-20, 24-26, 31, 34-36, 40, 41, 44-47, 49-52mass associated (with structural alteration), 35mastectomy, 44, 46mastitis, 23, 25, 26, 41mastitis of plasmatic cells, 23, 25medio-lateral-oblique (MLO), 40, 44, 45, 49, 50medullary (see carcinoma)melanoma (metastasis of), 47menstruation, 17metal particles (foreign as body), 44metallic or barium markers for identifying dermic lesion, 19metastasis axillar, 18

to the breast, 46microcalcifications (see calcifications)microcysts, microcystic (see calcifications)microlobulated (see contour)miscellaneous, 43MLO (see medio-lateral-oblique)mucin (in relation to microlobulated contours), 34

165

I N D E X

multicentral, multifocal, 36

N

needle (see biopsy)neurofibroma, 19nevus, 19, 51nodule, nodule/mass in benign category, 24

in malignant category, 39in normal category, 18in probably benign category, 29in probably malignant category, 33lobulated, 34multiple, 18, 26, 31of fatty density, 24of mixed density, 18, 24of water density, 24oval, 29polylobulated, 33round, 29

norm, normality (breast), 14, 20normal dense (breast), 17

fatty (breast), 17

O

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

P

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

166

I N D E X

positive predictive value (PPV), 24, 29, 31, 33postinfectious (see changes)postmastectomy reconstruction, 44postmenopausial (see changes)postoperative (see changes)postoperative scar, 26, 35, 40post-traumatic (see changes)potassium hydroxide (artefact by), 43powder (artefacts by), 43

dermic, 19hygiene, 19talcum, 43

PPV (see positive predictive value)pregnancy, 17, 46probability, 13, 33programme (screening), 7, 13, 14, 33, 39, 49, 52projectils (as foreign body), 43projections (mammographic), additional, 14, 23

CC (see craniocaudal)complementary, 30double, 34focalised, 19, 20lateral, 24, 25magnified, 19, 20, 25, 29, 35MLO (see medio-lateral-oblique)tangential, 19, 20

prolactin (and galactocele), 24prostheses, 44, 45protocol, 13, 17, 41, 49pseudocapsule (in hamartoma), 24pseudolymphoma, 41pseudonodule, 20pseudostar, 19punctiform, punctata (see calcifications)

R

radial scar, 25, 34, 40radiolucent, 19, 20, 24

halo in dermic lesion, 19radiotherapy, 25, 26, 41, 46radiotransparent (see prostheses)ramified (see calcifications)reading protocol, mammography, 13, 17

reading system (mammographic), 7, 13, 14, 29, 30, 52reductive (mammoplasty, surgery), 20, 40, 43reference hospital, 23, 36, 41

retraction, cutaneous, 21, 36of the nipple, 39, 40of the pectoral muscle, 39, 41

retroaerolar (see areolar)rheumatoid arthritis, 43, 45round (see calcifications)

167

I N D E X

S

sarcoma of soft parts (metastasis of), 47sarcoma of the breast, 46scars, 21, 25, 26, 43sclerosing ductal hyperplasia, 25

screening interval, 23, 29

sebaceous gland (calcification), 19sensitivity of the mammography, 17, 50

short term follow-up (mammographic), 14, 23, 24, 31, 52sign of tattoo (in dermic calcifications), 19

silicone (in prostheses), 44silicone injection (in prostheses), 44Sjöegren’s syndrome (in relation to prostheses), 45soaps (artefacts by), 43

sodium hydroxide (artefact by), 43soya oil (prostheses), 44spherical (see calcifications)spiculation, 33, 34, 39, 46spot-film (see focalised projection)stability (of lesions), 35star lesion (see stellate)stellate (nodule, image), 39, 40

stereotaxy (biopsy by), 36structural alteration in the benign category, 24, 25

in the malignant category, 40in the normal category, 19in the probably malignant category, 34, 35

superimposing, 19, 29, 33surgery, 20, 25, 40, 41, 43-45surgical biopsy, 29, 31, 36surgical specimen, 44suture, 20, 25, 43

T

tangential (see projections)tattoo (see sign of and artefacts by)tattoo marks (simulating microcalcifications), 43telorrhagia, 41thickening of the nipple-areola, 41

of the pectoral, 39traumatism (mammary), 20, 21, 25, 26, 40triglyceride (in prostheses), 44tubular (image), 30tubular (see calcifications)tumoral, 35, 39, 40tumorectomy, 20

168

I N D E X

U

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

V

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

W

warts, 18, 19, 51worksheet, 57

Z

zinc oxide (artefact by), 43

Prevention ofBreast Cancer

HEALTHCAREMONOGRAPH

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MAMMOGRAPHIC ATLAS

Reading System of Valencia Breast Cancer Screening Programme

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