PGMI (Perfect, Good, Moderate, Inadequate) is a method of evaluation of clinical image quality in mammography developed by the United Kingdom Mammography Trainers Group with the support of the Royal College of Radiographers, aimed to ensure the maintenance of a high standard of mammography in Br...
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words after bullets should not be capitalised unless they represent a name, e.g. Churg-Strauss syndrome will have "C" and "S" cap...
Medical devices in the thorax are regularly observed by radiologists when reviewing radiographs and CTs.
tubing, clamps, syringes lying on or under the patient
rubber sheets, foam mattresses, clothing, hair braids, nipple piercings etc may also be visible
These devices ...
The breast within a breast sign refers to the common mammographic appearance of breast hamartomas (fibroadenolipomas). Since these benign lesions are well-circumscribed and contain a mixture of fibrous, glandular and fatty tissue (just like normal breast), it is not surprising that they appear v...
There are many types of breast neoplasms, which can be divided into the following broad oversimplified categories as a starting point.
intra-lobular (epithelial and stromal)
metastasis to breast
Intralobular and interlobular refer to the terminal duct lobular ...
BIRADS V lesions under the BIRADS (breast imaging reporting and data system) refer to breast lesions that are highly suspicious for malignancy, requiring appropriate action to be taken (i.e. biopsy and management as appropriate). BIRADS V lesions have the characteristic morphology of breast canc...
Apocrine carcinoma of the breast is a rare variant of breast cancer. The diagnosis is mainly pathological as it is difficult to differentiate from other forms of breast cancer on imaging.
It accounts for about 4% of all cases. It is seen most often in females in the age group of 5...
Inflammatory carcinomas of the breast also referred as inflammatory breast cancers, are a relatively uncommon but aggressive form of invasive breast carcinoma which has a characteristic clinical presentation and unique radiographic appearances.
Inflammatory carcinomas account f...
Dr Albert Salomon (1883-1976) was the first physician to study x-rays of breast tissue.
Salomon worked at the Royal Surgical University Clinic in Berlin and from about 1913 x-rayed 3000 breast specimens obtained from the morgue in an attempt to identify breast pathology. He demonstrated tumour...
Galactoceles, also referred as lactoceles, are the most common benign breast lesion typically occurring in young lactating women; however, they mostly happen on cessation of lactation 1.
Patients usually present with a painless breast lump occurring over weeks to months....
Medullary carcinoma of the breast (MCB) is an uncommon subtype of breast cancer and accounts for ~5% 1,4 of all breast cancers.
They tend to occur more frequently in younger women than other breast cancer types 7. The mean age of presentation varies from 46-54 years but in 10% of ...
Diabetic mastopathy (DMP) is a condition characterised by the presence of a benign tumour like breast masses in women with long-standing type 1 or type 2 insulin-dependent diabetes. The condition has also been reported in men.
Diabetic mastopathy manifests clinically as a...
Architectural distortion is a mammographic descriptive term in breast imaging. It may be visualised as tethering or indentation of breast tissue.
Architectural distortion per se is not a mass. It is often due to a desmoplastic reaction in which there is focal disruption of the normal...
Asymmetrical mammographic density is a mammographic morphological descriptor. It is given when there is increased density in one of the breasts, on either one or both standard mammographic views but without evidence of a discrete mass. An asymmetrical density can be further characterised as:
Milk of calcium (MOC) is a term given to dependent, sedimented calcification within a cystic structure or hollow organ. This sort of colloidal calcium suspension layering can occur in various regions:
renal cysts: milk of calcium in renal cyst (most common)
breast cysts: milk of calcium in bre...
Oil cysts in breast imaging refer to benign breast lesions where an area of focal fat necrosis becomes walled off by fibrous tissue.
Non-tender palpable lump
Fat debris from ruptured lipocytes tends to conglomerate to form a macroscopic pool of ...
The pectoralis major muscle is a muscle of the pectoral region, overlying the anterior chest wall but is considered an upper limb muscle due to its function.
sternal part: sternum and superior six costal cartilages
clavicular part: medial half of the clavicle
A handy mnemonic to recall the causes of a stellate breast lesion is:
S: summation shadow
T: tumour (i.e. invasive breast cancer)
R: radial scar
F: fibroadenoma / fat necrosis
A: adenosis (sclerosing)
CE: other causes, haematoma (e.g. postoperative, post bio...
The causes of breast oedema can be remembered using the mnemonic:
V: venous obstruction
I: inflammatory breast cancer
L: lymphatic obstruction
S: surgery (recent)
A simple mnemonic to recall a list of commonly calcifying metastases is:
B: breast cancer
T: papillary thyroid cancer
O: ovarian cancer (especially mucinous)
M: mucinous adenocarcinoma (especially colorectal carcinoma)
A mnemonic to help remember breast lesion localisation when given a set of mammograms (MLO and CC) is:
muffins rise and lead falls
This can help localise the lesion into the quadrant (e.g. upper, outer) to make ultrasound correlation easier.
muffins rise: if the lesion is located me...
Abscesses are focal confined collections of suppurative inflammatory material and can be thought of as having three components 1:
a central core consisting of necrotic inflammatory cells and local tissue
peripheral halo of viable neutrophils
surrounded by a 'capsule' with dilated blood vessel...
In breast imaging, forbidden, check or review areas are zones that, according to Tabár, require special attention in mammographic interpretation.
on a mediolateral oblique (MLO) view
the "milky way" (retromammary fat): a 3-4 cm wide band parallel to the edge of the pectoral muscle...
Radial scar, or complex sclerosing lesion, is a rosette-like proliferative breast lesion. It is not related to surgical scarring. Some authors, however, reserve the latter term to lesions over 1 cm 5.
It is an idiopathic process with sclerosing ductal hyperplasia.
Its significance is that it...
Many patients, particularly in developing countries, present late with giant breast masses. They may be single or multiple and either benign or malignant. Many of these conditions are indistinguishable on physical examination alone. Some of these lesions require mastectomy while others can be tr...
Breast cancer staging uses the TNM staging system and then into stage groupings.
Primary tumour (T)
Tx: primary tumour cannot be assessed
T0: no evidence of primary tumour
Tis: carcinoma in situ
T1a: 0.1-0.5 cm
T1b: 0.5-1.0 cm
T1c: 1.0- 2.0 cm
T2: 2-5 cm
Apocrine metaplasia of the breast is a benign breast condition and is sometimes considered part of or associated with fibrocystic change. It is a common finding in the female breast, particularly after the age of 25, and many regard it as a normal component of the breast.
Mammography is a dedicated radiographic technique for imaging the breast.
Types of mammography
In general terms, there are two types of mammography: screening and diagnostic.
Mammography differs significantly in many respects from the rest of diagnostic imaging.
Phyllodes tumour, also known as cystosarcoma phyllodes, is a rare fibroepithelial tumour of the breast which has some resemblance to a fibroadenoma. It is typically a large, fast growing mass that forms from the periductal stroma of the breast.
Phyllodes tumours account for less t...
The anatomy curriculum is one of our curriculum articles and aims to be a collection of articles that represent the core anatomy knowledge for radiologists and imaging specialists.
Head and neck anatomy
Abdominal and pelvic anatomy
The percutaneous breast biopsy is one of the current choices for focal histopathological assessment of breast lesions. In contrast to fine needle aspiration, during a core needle biopsy, a hollow needle is used to withdraw small cores of tissue from the area of interest in the breast.
Ultrasound guided percutaneous breast biopsy is a widely used technique for an accurate histopathological assessment of suspected breast pathology. It is a fast, safe and economical procedure.
Ultrasound guidance is limited to lesions visible on ultrasound study, such as:
Atypical lobular hyperplasia (ALH) is a pre-malignant lesion of the breast which falls at the milder end of the spectrum of lobular neoplasia. It is therefore considered a part of borderline breast disease.
It is usually asymptomatic and mammographically occult and is in...
Breast angiosarcomas are a rare vascular breast malignancy.
As primary tumours of the breast, they account for ~0.04% 2 of all breast cancers and tend to occur in younger women, in their 3rd to 4th decades. Secondary angiosarcoma has an estimated incidence of ~0.09-0.16% and occur...
Accessory breast tissue is a relatively common congenital condition in which abnormal accessory breast tissue is seen in addition to the presence of normal breast tissue. This normal variant can present as a mass anywhere along the course of the embryologic mammary streak (axilla to the inguinal...
The presence of skin thickening on mammography is variably defined, usually being more than 2mm in thickness. It can result from a number of both benign and malignant causes. They include:
inflammatory breast cancer: one of the most concerning causes of skin thickening: this usually ...
Punctate microcalcifications in the breast are defined as calcific opacities <0.5 mm in diameter seen within the acini of a terminal duct lobular unit.
rarely in DCIS: punctate, clustered, segmentally distributed
Seromas are collections of serous fluid that usually occur as a complication of surgery, but can also be seen post-trauma. It is most commonly associated with post-breast surgery, where a potential space is left.
Seromas are distinct from a haematoma as it contains almost no red bl...
Popcorn calcification in the breast is the classical description for the calcification seen in involuting fibroadenomas which, as the name suggests, has a popcorn-like appearance.
A fibroadenoma in the long run may degenerate and calcify. Initially there are a few punctate periphera...
Eggshell calcifications in the breast are benign peripheral rim like calcifications
They are typically secondary to fat necrosis or calcification of oil cysts.
thin rim-like calcification (<1 mm in thickness)
small to several centimetres in di...
The tent sign is a term referred to a characteristic of the posterior edge of the breast parenchyma when a mass (usually an infiltrating lesion) causes its retraction and forms an inverted "V" that resembles the tip of a circus tent.
The detection of a "tent-sign" is facilitated by the systemat...
Snowstorm sign may refer to:
snowstorm sign: complete hydatiform mole (ultrasound)
snowstorm sign: extracapsular breast implant rupture (ultrasound)
Intraductal papillomas, or more specifically solitary intraductal papillomas of the breast, are benign breast lesions. Papillomas are the most common intraductal mass lesions of the breast.
Typically present in women in their late reproductive or postmenopausal years (with an aver...
Each breast lobe is drained by a collecting duct terminating in the nipple. The collecting duct has several branches, which ends in a terminal ductal-lobular unit (TDLU), the basic functional and histopathological unit of the breast. The TDLU is composed of a small segment of the terminal duct a...
With increasing use of screening mammography and ultrasound for various indications, a large number of non-palpable breast lesions are being detected.
Among this large number of non-palpable masses, not all are malignant. The incidence of malignancy among these non-palpable lesions varies betwe...
Step-oblique mammography is an accurate technique for determining whether a mammographic finding visible on multiple images on only one projection (but not elucidated using standard additional mammographic projections) represents a summation artefact or a true mass and for precisely localizing t...
Fat necrosis within the breast is a pathological process that occurs when there is saponification of local fat. It is a benign inflammatory process and is becoming increasingly common with the greater use of breast conserving surgery and mammoplasty procedures.
Most at risk are mi...
Triangulation is a technique for determining if a questionable structure is genuine or superimposition of structures.
hang the CC, MLO, and 90° lateral films (in that order) on the view box
the nipple on each film must be at the same level
use a ruler and place one end over the les...
Ultrasound evaluation of breast cysts is the modality of choice. Obstruction of the ducts, often appearing as the result of epithelial hyperplastic processes or the stromal fibrosis, or both processes lead to the formation of cysts, disabling the drainage of the terminal ducts of the lobules.
The nipple areolar complex is a major anatomic landmark of the breast. It may be affected by variation in its embryological development, breast maturation and also by other benign and malignant conditions.
nipple retraction or inversion
Artifacts that mimic breast calcification can arise from a number of sources. These include:
deodorants on skin: most practices recommend that clients for mammography do not use deodorant or perfume on the day of the study for this reason. The residue from deodorant is a very fine, dense, misty...
Breast density on mammography can significantly vary between individuals. The density is a function of the relationship between radiolucent fat and radiodense glandular tissue.
Breast density varies with age and generally younger women have denser breasts (i.e. more glandular tissue relative to...
The breast MRI classification flowchart (or Tree algorithm) is an evidence-based clinical decision rule to distinguish benign from malignant lesions in breast MRI. It incorporates five diagnostic criteria that are mainly consistent with BI-RADS though assigning diagnostic weights.
Adenoid cystic carcinoma (ACC) of the breast is a rare subtype of breast cancer.
They account for only 0.1-0.4% of all breast cancers.
The tumour demonstrates a strikingly characteristic microscopic pattern similar to that of adenoid cystic carcinoma of the salivary gl...
Adenoid cystic carcinomas are a rare histological subtype of adenocarcinoma.
Adenoid cystic carcinomas are generally considered low grade 4. The tumours have a notable tendency for perineural spread.
They have a wide distribution and mainly occur in relation to the airways...
20° oblique projection is a troubleshooting projection used in mammography, especially in young women and in follow-up patients.
The C-arm is turned approximately 20° for a superomedial-inferolateral oblique. With the patient's feet pointing towards the unit and her torso turned slig...
The posterior nipple line (PNL) refers to a line drawn posteriorly and perpendicularly from the nipple towards the pectoral muscle on the mammogram. In an adequately exposed breast, the measurement difference of this line between a CC view and MLO view should be ideally within 1 cm. It is the fi...
The tattoo sign is a feature given to describe dermal calcifications seen on mammography 1. The basis of this sign is that dermal calcifications maintain fixed relationships to one another which are reproducible with similar projections at different times. This is in contrast to intramammary cal...
A metastatic intramammary lymph node refers to an intramammary lymph node involved with metastatic or malignant disease.
Sonographic features that suggest metastatic involvement include 4:
disappearance or loss or central echogenic hilar region
Li-Fraumeni syndrome is a hereditary cancer syndrome due to mutations in the tumour suppressor gene TP53. Approximately half of affected individuals are thought to develop invasive cancer by 30 years of age 1.
Balloon breast brachytherapy (BBB) is a technique for delivering radiation treatment in women with early stage breast cancer. It is given after lumpectomy, or surgical removal of a small breast neoplasm, and is a shorter alternative to the more traditional method of external beam radiation for s...
Breast MRI is the most sensitive method for detection of breast cancer. Depending on international health regulations, it is either applied for screening of women at high risk for developing breast cancer (e.g. BRCA-1 and BRCA-2 carriers), as an additional diagnostic test in pretherapeutic breas...
Poland syndrome refers to a congenital unilateral absence of the pectoralis major and minor muscles and is a recognised cause of unilateral hyperlucent hemithorax.
Poland syndrome is usually sporadic, although rare familial cases have been described 1. It is rare, with an estimat...
The supraclavicular lymph nodes are a paired group of lymph nodes located on either side in the hollow of clavicle close to the sternoclavicular joint. It is the final common pathway of the lymphatic system as it joins the central venous system. They oversee transport of lymph from the thoracic ...
During the 6th week of gestation, a pair of longitudinal thickening of the epidermis develop on the ventral surface of the embryo, extending from the axilla to the medial thigh, called "mammary ridges" (or "mammary line", “milk lines"). In large part these milk lines later atrophy, leaving only...
Montgomery tubercles are the openings of Montgomery glands on the skin surface.
They are about 1-2 mm papules on the skin surface located on the skin of the nipple and areola.
These tubercles become prominent during stimulation and pregnancy
They are named after Wi...
Montgomery glands are large sebaceous glands in the breast, representing a transition between a mammary gland and a sweat gland.
Located within the nipple-areolar complex, Montgomery glands open onto the skin surface via protrusions on the skin known as Montgomery tubercles. They...
The foramen of Langer is a defect in the deep pectoralis fascia. It is a defect at the level of the third intercostal space, through which the upper lateral portion of the breast extends into the axilla forming the axillary tail of Spence.
The crests of Duret attach the most numerous superficial breast lobes by their summit to the superficial layer of fascia. The deepest crests connect the anterior lobes to the deep layer through the Cooper's ligament.
Breast lobe groups about one hundred lobules separated by interlobular connect...
Cooper ligaments are the fibrous connections between the inner side of the breast skin and the pectoral muscles. Working in conjunction with the fatty tissues and the more fibrous lobular tissues, they are largely responsible for maintaining the shape and configuration of the breast. They play a...
Axillary lymph nodes (LN) are in the axilla and receive lymph from vessels that drain the arm, the walls of the thorax, the breast and the upper walls of the abdomen.
There are five axillary lymph node groups, namely the lateral (humeral), anterior (pectoral), posterior (subscapu...
Amastia is a rare congenital condition characterised by the absence of breast tissue, nipple and areola. This may occur unilaterally or bilaterally.
During embryological development, breasts first appear as ectoderm ridges during the 6th week of gestation. This ridge grows thicker an...
Cavernous venous malformation, also traditionally referred to as a cavernous haemangioma (despite it not being a tumour) or cavernomas, are non-neoplastic slow flow venous malformations found in many parts of the body.
Despite the ubiquity of use of the traditional terms cavernoma...
Breast hamartoma (also known as a fibroadenolipoma) is a benign breast lesion.
They typically occur in women older than 35 years of age.
While it can present as a painless soft lump, it may also present as unilateral breast enlargement without a palpable l...
A magnification view in mammography is performed to evaluate and count microcalcifications and its extension (as well the assessment of the borders and the tissue structures of a suspicious area or a mass) by using a magnification device which brings the breast away from the film plate and close...
Gynaecomastia refers to a benign excess of the male breast tissue, that is usually reversible. It is not a risk factor per se for developing male breast cancer.
While it can occur at any age, it tends to have greater prevalence in two groups: adolescent boys and older men (some pu...
A ductal adenoma of the breast is a benign glandular tumour of the breast that usually fills and distends the ductal lumen.
They may occur in women of all ages, although the majority of patients are 60 years of age or greater 3.
Ductal adenomas usually pres...
Linguine sign is one of the imaging signs of intracapsular rupture of a breast implant.
After implantation of a silicone or saline breast implant, a fibrous capsule (scar) forms around the implant shell. In an intracapsular rupture, the contents of the implant are contained by the fibrous scar,...
Step-and-shoot is a technology of image acquisition in digital breast tomosynthesis characterised by stop scanning at every single angle during images acquisition.
Step-and-shoot technology allows advantages in microcalcifications conspicuity, spatial resolution, signal-to-noise Ratio improveme...
Nevoid hyperkeratosis of the nipple and the areola (NHNA) is a rare, idiopathic and benign dermatological condition.
Most often seen in females of reproductive age, especially during 2nd and 3rd decades of life. Less than 70 cases have been reported till now.
Infiltrating syringomatous adenoma of the nipple is a relatively rare, benign dermal neoplasm in the areola and nipple.
Syringomatous adenomas of the nipple usually present as unilateral 1 to 3 cm firm lesion in the subareolar or nipple region of the breast. Tenderness, i...
Lymphatic drainage of breast originates from breast lobules and flows into a subareolar plexus, called Sappey’s plexus. From this plexus, lymphatic drainage takes place through three main routes:
axillary or lateral pathway
fed by Sappey’s Plexus, as well as by ducts satellite lymphatics and b...
Aberrations in the Normal Development and Involution of the breast (ANDI) is an all-encompassing term that is used to describe a wide spectrum of the benign breast diseases. As the name suggests, it is based on the theory that most of the encountered benign breast disorders are essentially minor...
Fibrocystic change of the breast (also known as diffuse cystic mastopathy) is a benign alteration in the terminal ductal lobular unit of the breast with or without associated fibrosis. It is seen as a wide spectrum of altered morphology in the female breast from innocuous to those associated wit...
Breast involvement in granulomatosis with polyangiitis is seen in patients with avid systemic manifestations.
Clinically they can mimic carcinoma as a palpable, tender mass.
Granulomatosis with polyangiitis (or formerly known as Wegeners granulomatosis) is a ...
A juvenile fibroadenoma of the breast is a term given to a fibroadenoma presenting in children or adolescents. These may account for ~0.5-2% of all fibroadenomas, and are rapidly growing masses that cause asymmetry of the breast, distortion of the overlying skin, and stretching of the nipple.
Scirrhous carcinoma of the breast is a pathological sub type of breast cancer. It is a sub type of invasive ductal carcinoma not otherwise specified and present as a hard lump. The proportion of pathologic lymph node metastasis among scirrhous carcinomas is significantly higher than that among c...
Stepladder sign is a sonographic sign indicating an intracapsular breast implant rupture. It is considered the most reliable ultrasonographic finding in silicone gel breast implant intracapsular rupture. It is identified as multiple, discontinuous, parallel, linear echoes in the lumen, and is an...
Primary osteosarcoma of the breast is an uncommon breast malignancy and is a sub type extraskeletal osteosarcoma.
While it can present in a wide are group, the peak age at presentation is around the 6th decade 7.
The presence of bone in breast lesions is not diagnosti...
Dual-energy digital mammography is a complementary breast imaging modality.
The technique consists of high-energy and low-energy digital mammograms after administration of iodinated contrast agent.
Breast is exposed to low- and high-energy X-ray beams during a single breast compression in MLO ...
Microglandular adenosis (MGA) of the breast is a pathological subtype of mammary adenosis. It is benign breast condition although can mimic a breast cancer (particularly tubular breast carcinoma 3,5) both clinically, radiology and pathologically.
It is considered the only benign brea...
Breast manifestations of neurofibromatosis type 1 (NF1), or von Recklinghausen disease, it is characterised by multiple subcutaneous neurofibromas affecting the breast.
For a general discussion of the underlying condition, please refer to the article on neurofibromatosis type 1.
An automatic full-field volumetric breast ultrasound scanner (AFFBUS) is a developing technology which was initiated to overcome the drawback of dense breast and to get a three-dimensional view of the breast.
Automatic ultrasound imaging ac...