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.

What is a ‘Diagnostic Follow-up’? (What, Why, Where & How?)

Diagnostic follow-up is a method of further investigation of a lesion or anomaly revealed by careful routine clinical or radiological examination of the breast.

Coned Compression Spot Views:

1. Large Focus X-ray Beam

2. Film Receptor

3. Lesion

4. Small Compression Paddle with Small Aperture

Target Area:

• Small superimposed mass

• Mass with partially obscured borders

• Mass with indeterminate characteristics

• Mass with ragged or spiculated edges

• To demonstrate the obscured or indistinct anomaly clearly and free of superimposed tissue

How to Position a Coned Compression Spot View:

• Identify and localize the lesion to be studied

• Use the large focal spot (.3mm) with the grid and bucky in place

• Position the breast in the CC position

• Place a small mark on the skin directly over the location of the abnormality

• Use the smallest compression paddle and aperture possible in view of the size of the anomaly

• Vigilantly identify the projection and laterality

• With the mass centered in the small aperture, compress the breast as vigorously as possible to clear the mass of superimposed tissue

• Expose the image

• Position the breast in the MLO position

• Place a small mark on the skin directly over the site of the lesion in this projection

• Again, use the smallest paddle/aperture combination possible with the large focal spot

• Vigilantly mark the side and projection

• Carefully center the mass and compress vigorously to clear the mass’s borders and expose

• Assess the images to assure that targeted abnormality is centered on the film, it is clear of all super-imposition and is penetrated adequately

Coned Magnification Spot View:

1. Small Focus X-ray Beam

2. Film Receptor

3. Magnification Table with ‘Air-Gap’

4. Magnified Image of Lesion

5. Lesion

6. Small Compression Paddle with Small Aperture

Target Area:

• A new cluster of calcifications

• An increase in existing calcifications

• A change in the configuration, form or size of calcifications

• A irregular or spiculated mass containing fine calcifications

• Surgical or core biopsy specimen

How to Position a Coned Magnified Spot View:

• Using the scout images identify and localize the area to be magnified

• Use the small focal spot (.1mm) and the film holder without the grid and bucky

• Attach the magnification table at the appropriate magnification for the lesion in question (X1.5, X1.8 or X2)

• Use the least magnification possible and still visualize the area properly because the larger the level of magnification the greater the distortion in the image

• Position the breast in the CC position

• Place a small mark on the skin directly over the area of calcification

• Use the smallest compression paddle and aperture that adequately covers the entire area of interest

• Vigilantly identify the projection, laterality and the level of magnification

• With the skin marker centered in the small aperture, compress the breast as vigorously as reasonably possible to separate and discriminate between calcifications

• Expose the image

• Position the breast in the 90º lateral projection (magnification views of calcifications MUST always include a true lateral view to indicate the presence of ‘milk-of-calcium’)

• Again, place a small mark on the skin adjacent to the area of calcifications in this projection

• Using the small paddle and aperture; center the skin marker and compress the breast as vigorously as the patient can tolerate

• Diligently identify projection, side and magnification level

• Expose the image

• Repeat the procedure for the MLO projection and any other views deemed appropriate or useful (the CC & ML or LM projections are the routine magnification views)

• Assess all the images to verify that the calcifications are all well seen, distinct, clear of superimposition and separate

Roll and Turn View:

1. Superior Breast Lesion

2. Inferior Breast Lesion

1. Superior Breast Lesion Moves Medially

2. Inferior Breast Lesion Moves Laterally

3. Superior Aspect of Breast Turned Medially

4. Inferior Aspect of Breast Rolled Laterally

Target Area:

• To separate superimposed tissue

• To confirm the presence of an abnormality

• To better define a lesion

• To determine the validity and location of an anomaly seen in the CC view

How to Position a Rolled/Turned View:

• Position the patient in a true CC projection centering the identified abnormality in the midpoint of the image

• Place one hand on the superior aspect of the breast and one on the inferior aspect.

• Lift the breast up slightly and ‘Roll’ the top hand toward you and ‘Turn’ the bottom hand away from you (or visa/versa).

• Secure the breast on the bucky, holding the ‘rolled’/’turned’ tissue in place.

• Slide your supporting hand out as the final compression takes hold.

• The direction of the roll/turn (medial or lateral) must be clearly indicated on the film so that you can determine whether the lesion resides in the superior or inferior aspect of the breast.

• A superior lesion moves in the same direction of the roll and an inferior lesion moves in the opposite direction to the roll.

Tangential View:

Lesion located at the 6 o’clock position is demonstrated closest to the skin-line in the 90º lateral projection.

1. Lesion identified at 6 o’clock position

2. Marker placed on patient’s skin directly over lesion

Target Area:

• To project a demonstrated lesion as close to the subcutaneous fat as possible to free it from surrounding parenchyma.

• To establish or exclude micro calcifications as ductal or dermal.

How to Position a Tangential View:

• Place a small visible skin marker on the breast directly over area of concern.

• Marker must be placed on the correct surface. Place the skin marker over the lesion where the abnormality is closest to the skin.

• Correct placement of the skin marker is essential; the fenestrated or multi-hole location paddle can be useful for this purpose.

• Rotate the C-arm and breast tissue until the shadow of the skin marker is projected onto the bucky. This ensures that the lesion or calcifications are tangential to the beam.

Ultrasound:

Ultrasound shows a simple cyst by demonstrating a well circumscribed, thin walled, anechoic structure. There is sharp back wall and enhanced posterior shadowing.

Ultrasound shows a typical fibroadenoma by demonstrating a well circumscribed, hypo echoic nodule with homogeneous echo texture. Its long axis is parallel to the skin and there is enhanced through transmission.

Ultrasound shows an irregular spiculated lesion by demonstrating a poorly circumscribed hypo echoic mass with no through transmission and heightened posterior shadowing. The lesion is greater in height than it is in width.

Target Area:

Ultrasound is not a good screening tool but it is an excellent adjuvant instrument to establish criteria relating to anomalies detected by screening mammography, clinical breast examination or breast self examination. Ultrasound gives us exceptional details of lesions seen or felt in the breast. U/S can determine a whether or not a lesion is a simple cyst with higher than 99% accuracy. It can pinpoint many breast abnormalities for FNA or Core Biopsy. Since U/S’s preferred pallet is parenchyma and not fat as in mammography it can untangle many lesions in the mammographically dense breast.

SUMMARY

Screening mammography makes up a great deal of our daily routine. When we discover some change in the normal parenchymal pattern or find a burgeoning problem in the breast then we have accomplished what we set out to do. Investigating the tiny seemingly innocuous changes in the breast is what our job is all about. Breast imaging is all in relation to ‘do sweat the small stuff’. Find out what the changes mean and save a life!

Until next time friends,

Anne