Mammographic Masses/Calcifications Flashcards
definition of mammographic mass
space occupying lesion with convex borders seen on 2 projections
definition of asymmetry
seen on a single view
BI-RADS lexicon for margins
COMIS
circumscribed, microlobulated, obscured, indistinct, spiculated
Margins: circumscribed
75% of margin well-defined, remainder obscured by tissue
generally benign
Margins: microlobulated
finely irregular or serrated edge
Margins: obscured
25% hidden or superimposed by adjacent normal tissue
mass may be circumscribed but margin hidden by overlying tissue
Margins: indistinct
poorly defined margin raises concern that lesion may be infiltrating
Margins: spiculated
linear densities radiate from mass
malignant until proved otherwise
BI-RADS lexicon for density
radiolucent, low density, equal density, high density
breast cancers typically have ___ density compared to surrounding fibroglandular tissue
equal/higher density
BIRADS lexicon for shape
round, oval, lobular (undulating contour), irregular
when to use quadrants vs clockface?
quadrants: mammography
clockface: ultrasound
Associated features in mammography
architectural distortion, microcalcifications (malignant ductal calcifications), skin retraction, nipple retraction, skin thickening, trabecular thickening, axillary adenopathy
pathophysiology of architectural distortion
tethering of normal fibroglandular tissue
causes for skin retraction
postsurgical; desmoplastic tumor reaction
causes for skin thickenng
edema, prior radiation therapy
causes of trabecular thickening
edema or prior radiation therapy
when to perform spot compression magnification
characterize indeterminate/suspicious calcifications
mammogram technique for magnification
air-gap technique and small focal spot (0.1 mm)
skin calcifications finding
BIRADS 2
punctate/lucent centered, medially located
may need tangential view to delineate
vascular calcification findings
BIRADS 2
large rod like calcifications
early/incomplete vascular calcifications may appear suspicious
popcorn/coars calcifications
BIRADS 2
involuting/hyalinizing fibroadenoma
typically pripheral –> chunky popcorn appearance
large rod-like calcifications
BIRADS 2
secretory disease/plasma cell mastitis/duct ectasia (postmenopausal females)
ductal distribution similar to DCIS but large and rod-like
milk of calcium calcifications
BIRADS 2
free-floating calcium in tiny benign cysts; change in CC/lateral views
semilunar or crescent shaped due to dependent layering
sutural calcifications
BIRADS 2
calcium deposited on sutures, typically after radiation therapy
less common due to changes in modern surgical technique
dystrophic calcifications
BIRADS 2
s/p surgery, biopsy, trauma, irradiation
round calcifications
BIRADS 2
various etiologies
punctate calcifications
BIRADS 2
round, <0.5 mm;
however, a cluster may warrant more observation
lucent centered calcifications
BIRADS 2; 1 mm-1cm in diameter
eggshell/rim calcifications
BIRADS 2
calcium in a sphere, oil cyst
fat necrosis or cyst with calcified walls
amorphous/indistinct calcifications
BIRADS 4
too small/hazy to ascertain morphology
usually benign but mag views are needed if they seem clustered, regional, linear, or segmental distribution
coarse heterogenous calcifications
BIRADS 4
irregular calcifications >0.5 mm, smalelr than dystrophic calcifications
may represent early hyalinizing fibroadenomas or fat necrosis vs malignancy when new, warranting biopsy
fine pleomorphic calcifications
BIRADS 5
dot-dash appearance; suspicious for malignancy like DCIS or invasive ductal carcinoma
fine linear/branching calcifications
BIRADS 5
highly suspicious for malignancy
suggests filling of lumen of duct system involved by DCIS
Distribution terminology
BENIGN
-diffuse/scattered; regional
SUSPICIOUS
-linear, grouped/clustered, segmental
diffuse/scattered calcifications
randomly between breast, often bilateral
fibrocystic change/sclerosing adenosis
regional calciications
distributed in large volume (>2 cc) of breast tissue, not in ductal distribution
involves most of a quadrant
linear calcifications
arranged in line
segmental calcifications
secretory/rod like sgmental distribution benign
intermediate suspiciou (amorphous) or round/punctate calcifications in a segmental distribution
grouped/clustered calcification
cluster: 5+ calcifications in <1cc of tissue
cluster is more worrisome than grouped
when to use spot compression MAGNIFICATION
spot compression: evaluate focal suspicious mammographic abnormality
magnification used for calcifications
if asymmetry disappears on compression views?
if asymmetry doesn’t disappear?
abnormality likely superimposed normal plaible fibroglandular tissue NOT parenchymal fibrosis from desmoplastic reaction
if it does not change when compressed then suspicious and better characterization of margins –> US
what are the XCCL and XCCM views?
exagerrated craniocaudal views which pulls medial and lateral breast into detector
rolled views
CC variant; localize lesion seen on CC view only
RCCM and RCCL as breast is rolled medially and laterally.
if lesion moves medially with RCCM?
if lesion moves laterally with RCCM?
medially -> superior breast
laterally –> inferior breast
reduced compression
reduced compression to image far posterior lesion that slip out of detector
ML/LM views
true lateral views (ML most common); place lesion closest to detector
XR pass through medial breast and lateral breast is where detector is
how is true lateral view used to triangulate lesion?
triangulate lesion seen only on MLO view
if lesion rises on lateral view, lesion located in medial breast
if lesion sinks, it is in lateral breast
medial: muffins rise; lateral: lead sinks
if pt gets BIRADS 0, next step?
recalled for additional evaluation and spot compression views are obtained
if normal: BIRADS 1/2
if asymmetry persist: orthogonal views
>MLO only –> lateral views, or XCCL, rolled CC
> CC only –> upper inner quadrant lesion; get rolled views
once lesion localized to quadrant –> US
if lesion cannot be localized –> MRI
when to biopsy
mass with any suspicious feature on US or mammography
how long of stability to call a mass benign?
2 years
workup for palpable mass?
all palpable findings are evaluated by ultrasound even in mammogram is negative
when to give BIRADS 3
1) circumscribed benign appearing solid mass
2) cluster of punctate/round calcifications
3) focal asymmetry (non palpable lesion seen on 2 projections; usually interpersed with fat)
developing asymmetry
focal asymmetry that has increased in size and is suspicious
