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.