B-B-B-BLURRING! (Part 1 of 3)

The definition of blurring or un-sharpness on mammography images is: the amount of lateral border spread along the edges of our image. A distance of border spread that is visually acute is unacceptable.

What causes our images to look blurry? Why do the x-rays sometimes look indistinct? What can we do, where can we seek an answer?

There are three distinct causes of mammography blurring:

• Motion
• Geometric
• Receptor

Motion:

To control motion on our images we simply must do all we can to prevent the subject from moving during the exposure.

To control motion we need the correct amount and application of compression. The amount of compression depends upon the tolerance of the patient, the size, shape, consistency and habitus of the breast. The breast should be compressed until the edges feel taut and there is no allowable ‘squeezability’ of the breast.

To achieve adequate compression it is essential to prepare the patient. An informed patient that is aware of the reason for compression, the length of time her breast will be compressed, the fact that you will not go past the point of discomfort into real pain is relaxed, in control and more likely to cooperate. Take as much time as you need before the test to explain, demonstrate, empower and inform. It will save time in the long run.

To achieve high contrast images in breast imaging a low kVp is usually implemented. This is generally the best course of action but it also instigates a longer time of exposure to obtain adequate exposure. The length of time of the exposure is critical to the cessation of motion. If for any reason (age, infirmity, palsy, or weakness) your patient will not be prepared to remain still for such a long exposure it is prudent to initiate a higher kVp in order to shorten the exposure time. This is also true for patients with thick, dense impenetrable breast tissue that would engender an extremely long exposure. A sharp image obtained at higher kVp levels is far better than a blurry image obtained with lower kVp levels.

Finally we must employ a proper compression paddle with the following properties:

• A rigid lexan construction
• A 85º - 90º bend @ the chest wall edge
• The leading edge must be parallel to the film edge
• There must be at least a 4cm rise at the chest wall
• It must have a secure locking non-slip attachment to the unit

A Proper Compression Paddle Device:

An Unacceptable Type of Compression Device:

SUMMARY

Blurring is a major cause of error in interpretation of mammography images. It is imperative we understand and address all the causes of this difficulty. Motion is the first in the series on blurred images. Stay tuned for Geometric and Receptor problems.

“Lesion, Lesion, Where Is The Lesion?”

The radiologist cannot determine the characteristics of a lesion if it is only shown in one projection. He/she cannot even determine if the lesion is real or illusionary. When a lesion appears only in one view on a four view routine mammogram, we have to ask ourselves several pertinent questions before we start randomly taking useless extraneous projections.

1. Which projection does the lesion show in?
2. Where does the lesion fall in that projection?
3. Is the lesion real or made up of overlapping parenchyma?
4. What can we do to find the area in another projection?
5. How can we confirm that we have seen the lesion or overlapping area clearly in another projection?
   

Most commonly, an apparent lesion will appear in the MLO view and not in the CC projection. This is due to the fact that more breast tissue is imaged in this projection that any other view we take. To locate the area in the CC projection should be a planned excursion not a wild ride of random projections looking for ‘something’ illusive.

The Excursion From A Lesion Seen Only In The MLO View To Placement in CC Projection:

• Measure where the lesion falls in the MLO view. Take three measurements: the distance from the nipple, the distance from the superior edge and the distance from the inferior edge.
• Obtain a true lateral view of the breast, being sure to include the questionable area in the projection. Take the same three measurements: the distance from the nipple, the distance from the superior edge and the distance from the inferior edge.
• Hang the images on the viewbox with the Lateral view first, the MLO view in the center and CC view at the end. Be sure that the images are hung so the inferior/superior borders of the Lateral and MLO projections are aligned.
• Using a long ruler and a grease pencil draw a straight line from the lesion projected on the Lateral image through the same lesion on the MLO image and continue the line straight through the CC projection.
• Mark a * where the line ends at the distance the lesion measures from the nipple and that is where you will find your lesion on the CC view.

This method of locating the missing lesion is called Triangulation. This triangulation method can be used to find the lesion in any one of three projections. Set the films up in the same manner and draw the line through the two projections the lesion is visible in.


A: 90º Lateral B: MLO



Triangulating The MLO Lesion Into The CC Projection:

A useful rule to remember when using triangulation to locate a lesion in the CC projection is: If the lesion rises in the lateral projection the area will show on the medial aspect of the CC, if the lesion falls in the lateral view it will show-up on the lateral aspect of the CC. “M(medial)uffins rise and L(lateral)ead Falls”

Is The Lesion Real Or Just Overlapping Tissue?

Roll/Turn View With A Real Lesion:

1. Spiculated Mass
2. Dense Parenchyma

A spiculated lesion overlaps a dense parenchymal shadow making the lesion indistinct and difficult to see.

1. Spiculated Lesion
2. Dense Parenchyma
3. Superior Breast Tissue is rolled Medially
4. Inferior Breast Tissue is rolled Laterally

The irregular stellate lesion is thrown clear of the dense parenchymal shadow and therefore is easily seen and a coned compression F/U view can be easily taken.


Roll/Turn View With an Illusionary Or False Lesion:


1. Dense irregular parenchymal shadow
2. Dense irregular parenchymal shadow

Two dense irregular parenchymal densities combine to mimic a stellate lesion on the CC view. It is not clear on the MLO projection: Is it real?

1. Normal Parenchymal Density
2. Normal Parenchymal Density
3. Superior Breast Tissue Rolled toward the Medial Border
4. Inferior Breast Tissue Rolled toward the Lateral Border

Separated by the ‘roll/turn’ projection, it is obvious that the area seen in the CC projection was merely overlapping normal parenchymal tissue.

If It Is Real: Where is it in the MLO Projection?

If we see an irregular density in the CC view, prove by diagnostic F/U that it is an authentic mass, and still cannot verify where it is in the MLO view, how can we find it?



1. Spiculated Lesion
2. Dense Parenchymal Pattern


1. Spiculated Lesion
2. Dense Parenchymal Pattern
3. Superior Breast Tissue Rolled toward Medial Border
4. Inferior Breast Tissue Turned toward Lateral Border


Since we know which way we rolled & turned the superior & inferior borders of the breast. Then we can determine whether the lesion is superior or inferior by which way the lesion moves

In this case, the superior tissue was rolled medially and the spiculated lesion moved medially. Therefore we can conclude that the lesion we are interested in is in the superior aspect of the breast and the dense benign parenchyma was turned laterally in the inferior breast so conversely, it will be found in the inferior aspect of the breast.

1. Spiculated Lesion Located in the Superior Aspect of the Breast in the MLO View
2. Obviously Negative Parenchymal Tissue Located in the Inferior Aspect of the Breast in the MLO View


SUMMARY

It is our responsibility to make the lesions found in the routine mammograms apparent to the reading radiologist. The radiologist very often just tells us, “find the lesion”. If we know how to isolate, separate and identify those suspect areas we can help the radiologist, help the patient, save time, anxiety, technical resources, department finances and finally our mental health.

The Long Dark Journey Into Breast Cancer: From Normal Duct To Infiltrating Ductal Carcinoma

How The Journey Takes Place

Breast cancer doesn't start in the skin of the breast, the fat surrounding the breast tissue or the fibrous supporting structures of the breast. Breast cancer begins with the cellular lining in the breast ducts.

Cancers, all cancers, are cellular diseases. Cancer starts when the normal cell divides abnormally, becomes atypical, starts dividing eccentrically, refuses to die when the body tells it to, begins to affect the surrounding cells and, finally, the cell becomes malignant and begins to feed off healthy cells turning them malignant. These sick cells become a malignant tumor and the nasty business continues.

The Journey

• Step one, begins with a healthy terminal duct containing a thick continuous basement layer of cells lined with a homogeneous layer of identical epithelial cells each enclosing a single vigorous nucleus.

• Step two in the journey is normal hyperplasia. Hyperplasia is a normal effect of aging. As we age, the conventional 'die trigger' in the cells slows down and our characteristic epithelial cell layer begins to build up on itself. The cells still represent identical vigorous cells containing healthy nuclei.

• Step three along the path to breast cancer is atypical hyperplasia. Atypical hyperplasia is considered a pre-cancerous condition. The rapidly building hyperplasic cells begin to deteriorate. The walls of the cells become misshapen. The nuclei commence to look deformed. During this stage in the dark excursion the basement layer of cells remain intact and characteristic. At this step the dead cells are crowded together and sometimes the little dead cell bodies calcify. If this happens it is good because the tiny clusters of calcifications that represent the dead cells inside the duct can lead us to a burgeoning problem.

• Step four is ductal carcinoma in-situ or DCIS. Step four crosses the line from 'atypical' to cancerous. DCIS is the earliest stage of breast cancer and the most advantageous to find. At some stage in the atypia process one or a cluster of uncharacteristic cells become cancerous cells. We have no idea why this occurs, but when it does the process begins to intensify. The malignant cells rapidly collect healthy cells and alter their structure into cancer. These malignant cells begin to form a lesion or mass within the duct. This mass begins to elongate the duct, thin and stretch the basement cell layer. The malignant process tends to create a virtual graveyard of dead cells and if we are lucky these cells will calcify and we will be able to pick them up on a mammogram.

• Step five is infiltrating ductal carcinoma. By this stage in the grim excursion the malignant cluster of cells have broken out of the basement membrane of the duct and has begun to collect breast parenchymal tissue as food for the tumor. Infiltrating ductal carcinoma very often is seen as an ill-defined mass containing malignant type calcifications. Left undetected, infiltrating ductal breast cancer will become a large, palpable stellate mass which often represents a well established metastasized breast cancer.

SUMMARY

The whole point of high quality mammography screening is to find early signs of breast cancer. Our job is to create the best images we can using all the knowledge we possess about the disease we are trying to discover.

Know your enemy, know where it hides, know how it grows and know how to corner it.

Keep up the good fight.

Imaging The Augmented Breast

In the breast cancer patient who has had a complete mastectomy with no reconstruction it may not be necessary to use mammography to diagnose recurrent carcinoma. The incision site and very small slips of tissue at the chest wall are the only sites for recurrent tumor in these cases. Physical examination and/or axial radiography (CT or MRI) should be adequate to evaluate these patients for recurrence. With myocutaneous flap reconstruction, mammography can be useful in diagnosing fat necrosis.

Breast cancer patients with Tram/flap or Augmentation reconstruction will require a full routine, bilateral mammogram to assess the tissue unseen and unfelt underneath the reconstructed site. Clinical evaluation is difficult with post mastectomy reconstruction.

In women who have had breast augmentation implantation for cosmetic reasons evaluation must be two-fold. First, we must carefully screen these patients for early occult breast cancer and then, we must assess the status of the implant.

We can identify occult cancers in the parenchyma of women with implants by using the now well known ‘implant displacement’ or ‘push-back’ technique introduced by G. W. Eklund. These views are obtained by gently moving the implant superiorly and posteriorly toward the chest wall while extending the anterior parenchyma onto the buckey and into the compression. These views, along with views obtained with the implant in the x-ray field, plus any necessary 90-degree lateral or axillary views make up a comprehensive screening exam for silicon/saline implant patients.

The status of silicone implants must be investigated on a regular basis. Implants should be evaluated year after year for contour changes, focal bulges, changes in position, capsular calcification, linguine sign rupture or any high-density material outside of the implant capsule. Comprehensive physical examination, xeroradiography (excellent for this purpose), ultrasound, CT and MRI scanning are all used to great advantage as tools to evaluate the integrity of breast implants.

Implant Displacement Mammography

Implant & Push-Back Images

A. B. C. D.

A. LMLO Push-Back Projection

B. LMLO Implant-in-Place Projection

C. LCC Push-Back Projection

D. LCC Implant-in-Place Projection

Extended Left CC Implant-in-Place view

Laterally extended LCC implant-in-place view shows a nodule only partially imaged in the routine LCC push-back view (C).

Coned-Compression Magnified Push-Back XLCCL View

Coned-compression magnification view in an extended LCCL push-back projection illustrates an ill-defined, irregular mass containing malignant type calcifications.

SUMMARY:

As always, knowledge is power. The more we know about the ins and outs of augmentation the better we are equipped to deal with the intricacies of imaging patients with this type of surgery. It is easy to miss a small cancer hiding adjacent to a dense silicon implant. What we don’t image nobody sees!

What’s Good, What’s Bad, What’s What!?! (Malignant Breast Masses)

Assessing and demonstrating clearly an area of concern on our images is a long way from diagnosing disease. What is missed or obscured on our clinical images is not analyzed by the Radiologist. Therefore it is essential that we recognize a possible concern and know how to demonstrate it clearly.

Masses arise in the breast tissue for a variety of causes. Many breast lumps and masses are benign and triggered by normal physiological function of the breast organ. Some masses in the breast tissue can turn out to be dangerous malignant clumps of cells rapidly growing and consuming breast tissue. To demonstrate breast masses we first must appreciate their presence and then comprehend their characteristics.

The Characteristics of Malignant Breast masses:

CHARACTERISTIC	PROPERTIES
Shape	Variable Irregular Spiculated
Borders	Irregular Ill-defined Indistinct
Density	Non-homogeneous Mixed Densities
Size	Feels >++ than its Appearance
Affect on Surrounding Parenchyma	Mass Infiltrates & Retracts Surrounding Tissues
Associated Calcifications	Small Irregular Infiltrating Entire Mass Many Varying Calcifications
Secondary Signs of Ca.	Often Present

Malignant Breast Masses:

Malignant Breast Masses Include:

1. Vague Moderately Dense Lesions with Indeterminate Borders
2. Highly Dense Jagged Lesions with Retracted Edges
3. A Series of Interconnected Irregular Masses Following a Ductal Path
4. A Lesion with a Dense Center and Straight Spiculations Radiating 180º
5. Any Mass Containing Malignant Calcifications
6. A Radial Scar can be a Highly Suspicious Breast Lesion

Moderately dense breast lesions which are relatively regular shape can be highly suspicious for breast cancer if their borders are vague and indistinct. These lesions can represent invasive lobular carcinoma, tubular carcinoma, a small phyllodes tumor or medullary cancer.

A highly dense lesion in the breast with wildly irregular borders that infiltrates the surrounding breast tissue and retracts existing parenchyma is almost certainly a breast cancer. These lesions usually signify an invasive ductal cancer growing in the duct. This cancer has already broken through the basement membrane of the ductal system and has invaded the breast parenchyma.

A series of interconnected irregular masses joined together by narrow bands of dense parenchyma often accompanied by malignant type calcifications usually indicate a serious invasive multifocal breast cancer. This malignancy signifies a cancer growing through an entire lobe.

A stellate or star-shaped lesion with a very dense center containing tiny irregular calcification and short dense radiations almost certainly represents a pervasive retracting breast cancer. These lesions have dense even spicules diverging at 180º from a dense central core and the parenchyma is constantly being pulled into the center nucleus.

Even a smooth, regular mass with a lucent halo representing a typical benign mass can indicate breast cancer if it contains malignant category irregular casting or clustered calcifications.

A radial scar is a difficult lesion to identify and to categorize. It gives the impression of a stellate mass in the breast with wispy elongated arms that don’t always radiate the entire perimeter of the mass. The center of a radial scar is only moderately dense and is often studded with fat pockets. The breast tissue is being displaced, not retracted, by this phenomenon. The radial scar is in itself benign, but can represent a high propensity for the development of breast cancer and for that reason is often surgically removed.

SUMMARY

All masses and indeterminate lesions seen on our breast images should be noted, located and well demonstrated by today’s Mammographer. We should be well versed in the procedures of clarification and follow-up for such abnormalities. Coned compression views, lateral projections and ultrasound are the primary techniques used to further analyze masses. These views afford a clearer appreciation of the morphology and characteristics of the masses thus allowing the Radiologist to make informed diagnostic decisions.

The Mammographer within today’s modern team oriented department must have the advanced positioning and clinical skills to ensure the area of concern is appropriately imaged, clearly seen and able to be characterized by the Radiologist.

Masses in Breast: What’s Good, What’s Bad, What’s What?! (Benign Breast Masses)

Assessing and demonstrating clearly an area of concern on our images is a long way from diagnosing disease. What is missed or obscured on our clinical images is not analyzed by the Radiologist. Therefore it is essential that we recognize a possible concern and know how to demonstrate it clearly.

Masses arise in the breast tissue for a variety of causes. Many breast lumps and masses are benign and triggered by normal physiological function of the breast organ. Some masses in the breast tissue can turn out to be dangerous malignant clumps of cells rapidly growing and consuming breast tissue. To demonstrate breast masses we first must appreciate their presence and then comprehend their characteristics.

The Characteristics of Benign Breast masses:

CHARACTERISTIC	PROPERTIES
Shape	Round Oval Lobulated
Borders	Smooth/Regular Haloed Circumscribed
Density	Homogeneous Mixed with Fat and Parenchyma
Size	Feels <or= to Appearance
Affect on Surrounding Parenchyma	Mass Displaces Surrounding Tissues
Associated Calcifications	Large Chunky Around Edge Central Few in Number
Secondary Signs of Ca.	Not Present

Benign Breast Masses:

Varieties of Benign Breast Masses Include:

1. Cyst: smooth, moderate to high opaque center, with a lucent halo
2. Lipoma: smooth, lucent center, circumscribed
3. Fibroadenoma: smooth, moderately dense center, with a lucent halo
4. Fibroadenoma/Lipoma: smooth, mixed lucent & moderately dense center, with a ‘pencil-line’ border surrounded by a lucent halo
5. Oil Cyst: smooth, very dark gray homogenous lucent center, sharply delineated opaque border
6. Fat Necrosis: Often asymmetrical borders with rough edges, centers are mixed chunky large calcification and lucent fat.

CYST appears as a smooth round, oval or lobulated mass which is displacing the surrounding parenchyma. The center of the cyst is denser than the surrounding breast tissue. The cyst is well delineated and bordered by a lucent halo of fat.

LIPOMA appears as smooth regular shaped mass which is displacing the surrounding breast tissue. The center of the lipoma is equal to density of the existing fat inside the breast. The lipoma is outlined with a pencil thin opaque line. If the lipoma is situated inside the fat of the breast, it is sometimes difficult to recognize.

FIBROADENOMA is seen as a smooth round oval or lobulated mass which displaces the adjacent breast tissue. The center of the fibroadenoma is moderately dense, usually about equal density as the breast’s own parenchyma. The fibroadenoma is well defined and outlined with a lucent halo of fat.

FIBROADENOMA/LIPOMA presents as a smooth regular shaped well defined mass displacing the surrounding parenchyma. The center of a fibroadenoma/lipoma is mixed lucent fat equaling the density of the breast fat and moderately dense tissue usually just slightly denser than normal parenchyma. The fibroadenoma/lipoma is delineated with an opaque pencil line surrounded by a lucent halo.

OIL CYST presents as a regular shaped smooth mass that is not always completely distinct within the tissue. The oil cyst is filled with oily fluids caused by the body’s reaction to a trauma. This oil is very homogenous and appears very dark gray on the radiograph. The oil cyst is encircled by a thin opaque line that follows the injury site and therefore is not always completely distinguished.

FAT NECROSIS is caused by serious trauma to the breast tissue usually through surgical intervention or significant accident. It therefore tends to follow the scar beds in the breast and is not regular or smooth. A section of fat necrosis in the breast is filled with dead cells and oily fluids intended to heal the tissue. So, the central portion of fat necrosis is a mixture of large chunky calcified dead cellular material a homogenous gray fat. In its early post-op or post-trauma state it is difficult to determine whether the mass is fat necrosis or disease.

SUMMARY

All masses and indeterminate lesions seen on our breast images should be noted, located and well demonstrated by today’s Mammographer. We should be well versed in the procedures of clarification and follow-up for such abnormalities. Coned compression views, lateral projections and ultrasound are the primary techniques used to further analyze masses. These views afford a clearer appreciation of the morphology and characteristics of the masses thus allowing the Radiologist to make informed diagnostic decisions.

The Mammographer within today’s modern team oriented department must have the advanced positioning and clinical skills to ensure the area of concern is appropriately imaged, clearly seen and able to be characterized by the Radiologist.

Breast Calcifications: What’s Good, What’s Bad and What’s What! (Malignant Breast Calcification)

Assessing and demonstrating clearly an area of concern on our images is a long way from diagnosing disease. What is missed or obscured on our clinical images is not analyzed by the Radiologist. Therefore it is essential that we recognize a possible concern and know how to demonstrate it clearly.

Calcifications arise in the breast as a natural process of aging and can be grossly benign. Calcifications can also gather in the ductal paths of the breast parenchyma due to an atypical proliferation of dead or dying cells caused by the presence of some active pathology. To demonstrate breast calcification we first must appreciate their presence and then comprehend their characteristics.

Characteristics of Malignant Breast Calcifications:

CHARACTERISTIC	PROPERTIES
Form	Irregular Rod-Like Powdery
Size	Small to Tiny Usually < .5mm
Density	Varied Densities Light to Darker Densities inside
Distribution	Clusters of Tiny Groups Rod-Like Indian Lines All Within one Lobe Following a Duct
Margins	Irregular Edges Border Not easily Identified Indistinct Edges
Number of Calcifications	Many in a Group Overlapping and Not easily Counted
Position in Relation to Mass	Scattered all through the Mass Intruding into Surrounding Parenchyma

Malignant Calcifications:

Malignant Breast Calcifications Include:

1. Small Irregular Clusters Confined to a Lobe
2. Granular Clusters Following a Ductal Path from Nipple to Chest Wall
3. Fine Powdery Clusters of Barely Perceptible Specks Confined to One or Two Areas
4. Casting, Branching or Rod Shaped Following the Duct
5. Irregular, varied, indistinct associated with a ill-defined mass or spiculation
6. Malignant Fibroadenoma
7. Malignant Papilloma

Small clusters of irregular calcifications confined to one area, lobe or segment. The calcifications are of variable densities, sizes and shapes.

Granular, rod like or irregular clusters of numerous calcifications of varying densities, sizes and shapes following along one ductal path from the chest wall edge toward the nipple.

Fine powdery calcifications that are confined to a small section, lobe or lobule; they are usually difficult to perceive without magnification.

Irregular, casting, Indian-line or rod-like calcifications which branch through the ductal system from chest wall to nipple; these are of various sizes, forms, contours and densities.

Indistinct, irregular calcifications associated with a dense, asymmetrical, ill defined mass or a white-star spiculation. These calcifications may invade the tissue outside the mass as well as concentrating themselves in rough dense clusters within the lesion.

Malignant fibroadenoma are very rare. Most fibroadenoma are profoundly benign. Cancerous fibroadenoma contain clustered irregular or branching calcifications. Malignant fibroadenoma will appear atypical on mammography and on U/S.

Malignant Papilloma:

1. Main Duct

2. A interductal Papilloma with dense branching calcifications

3. Papilloma accompanied by a spontaneous bloody discharge

SUMMARY

All calcifications seen on our breast images should be noted, located and well demonstrated by today’s Mammographer. We should be well versed in the procedures of clarification and follow-up for such abnormalities. Tangential views will easily and efficiently locate calcifications for the Radiologist. Magnification and coned compression are the primary techniques used to further analyze calcifications. These views afford a clearer appreciation of the morphology and distribution of the calcifications thus allowing the Radiologist to make informed diagnostic decisions.

The Mammographer within today’s modern team oriented department must have the advanced positioning and clinical skills to ensure the area of concern is appropriately imaged, clearly seen and able to be characterized by the Radiologist.

Breast Calcifications: What’s Good, What’s Bad and What’s What?! (Benign Breast Calcification)

Assessing and demonstrating clearly an area of concern on our images is a long way from diagnosing disease. What is missed or obscured on our clinical images is not analyzed by the Radiologist. Therefore it is essential that we recognize a possible concern and know how to demonstrate it clearly.

Calcifications arise in the breast as a natural process of aging and can be grossly benign. Calcifications can also gather in the ductal paths of the breast parenchyma due to an atypical proliferation of dead or dying cells caused by the presence of some active pathology. To demonstrate breast calcification we first must appreciate their presence and then comprehend their characteristics.

Characteristics of Benign Breast Calcifications:

CHARACTERISTIC	PROPERTIES
Form	Smooth, Round, Oval Curved
Size	Quite Large Usually @ .5mm and Larger
Density	Uniform highly dense Dense with Lucent Areas of Fat
Distribution	Scattered, Surrounding a Smooth Mass, Following a vessel or Embedded in the Skin
Margins	Smooth, Rounded, Easily Seen and Followed
Number of Calcifications	Usually not more than 5 in a Group Always separate and easily Counted
Position in Relation to Mass	Either centered in the Core of a Smooth Mass Gathering Around its Edge

Benign Calcifications:

Benign breast Calcifications Include:

1. Blunt Duct Adenosis

2. Sclerosing Adenosis

3. Fibrosis

4. Arterial Calcification

5. Intra/Peri Ductal Plasma Cell Mastitis

6. Sebaceous, Skin Calcifications

7. Benign Papilloma

8. Eggshell Calcified Galactocele or Oil Cysts

9. Calcified Fibroadenomas

BLUNT DUCT ADENOSIS: Shows a fat for-shortened Terminal Duct Lobular Unit with clusters of calcifications at the base of the ductules

SCLEROSING ADENOSIS: Shows a long spidery elongated TLDU with rows of calcifications strewn along the length of the ductules

FIBROSIS: Shows a fat swollen badly misshapen TLDU with large smooth calcifications filling the distal ends of the ductules

ARTERIAL CALCIFICATIONS:

1. Artery

2. Calcified Internal Arterial Walls

INTERDUCTAL PLASMA CELL MASTITIS:

1. Terminal Duct Lobular Units

2. Branching Ducts

3. Intraductal Calcifications Stretching through the Length of the Ducts

PERIDUCTAL PLASMA CELL MASTITIS:

1. Branching Ducts

2. Periductal Calcifications Coating the walls of the Duct

SEBACEOUS/SKIN CALCIFICATIONS:

1. Skin Pore or Sebaceous Gland

2. Tiny Smooth Calcification

BENIGN PAPILLOMA:

1. Epithial Cell Layer

2. Interductal Papilloma

3. Scattered inter-lesion calcifications

4. Main or Large Branching duct

EGGSHELL TYPE CALCIFICATIONS: Very dense calcifications surrounding a central core mass. If the central core is OPAQUE, the mass very likely is a cyst with a calcified wall, a fibroadenoma or a Phase 1 galactocele. If the central core is RADIOLUCENT, the mass very likely is a calcified lipoma, an oil cyst, fat necrosis or a Phase 3 galactocele.

CALCIFIED FIBROADENOMA: Benign fibroadenoma can calcify in several ways.

Sub capsular calcifications are very dense inside layer of calcification coating the edge of the mass. These can appear linear or eggshell like. Fibroadenomas calcifying with central dense or mixed fat/calcified centers very often appear like pieces of sponge toffee or popcorn.

SUMMARY

All calcifications seen on our breast images should be noted, located and well demonstrated by today’s Mammographer. We should be well versed in the procedures of clarification and follow-up for such abnormalities. Tangential views will easily and efficiently locate calcifications for the Radiologist. Magnification and coned compression are the primary techniques used to further analyze calcifications. These views afford a clearer appreciation of the morphology and distribution of the calcifications thus allowing the Radiologist to make informed diagnostic decisions.

The Mammographer within today’s modern team oriented department must have the advanced positioning and clinical skills to ensure the area of concern is appropriately imaged, clearly seen and able to be characterized by the Radiologist.