BIRADS AND IMAGING OF BREAST

PATHOLOGIES

Dr.Archana Koshy

There are several breast imaging modalities

available such as Ultrasound, CT,Digital

Mammography ,MRI and scintimammography .

Mammography remains the cornerstone of breast

imaging .

Only mammography when correctly performed and

interpreted offers the necessary reliability to

diagnose the curable forms of breast cancers.

Ultrasound,MRI , CT are useful adjuncts once a

lesion has been detected by physical examination or

by radiographic mammography .

INDICATIONS

Screening of asymptomatic women

Screening of high risk women

Follow up of patients after mastectomy of same and

opposite breast / same breast with implant .

Investigations of benign breast diseases with

eczematous skin,nipple discharge , skin thickening .

Investigation of a breast lump

Investigation of occult primary with secondaries .

Male breast evaluation .

BIRADS Breast imaging- reporting and

data system

BIRADS

Latest version classifies lesions into 0 - 6 categories:

BIRADS 0: Incomplete, further imaging or

information is required. Eg: Compression,

magnification, special mammographic views,

ultrasound. This is also used when previous images

not available at the time of reading.

BIRADS

BIRADS I: Negative, symmetrical and no masses,

architectural disturbances or suspicious calcification

present.

BIRADS II: Benign findings, interpreter may wish to

describe a benign appearing finding. Eg: Calcified fibro

adenomas, multiple secretory calcifications, fat

containing lesions like Oil cysts, breast lipomas,

galactoceles and mixed density hamartomas, simple

breast cysts.

These lesions should have characteristic appearances

and may be labeled with confidence and make sure there

is no mammographic evidence suggesting malignancy.

BIRADS

BIRADS III: probably benign, short interval follow up

suggested.

BIRADS IV: suspicious abnormality.

There is mammographic appearance which is

suspicious of malignancy.

Biopsy should be considered.

BIRADS IVa: low level of suspicion

BIRADS IVb: intermediate level of suspicion

BIRADS IVc: moderate level of suspicion for

malignancy

BIRADS

BIRADS V: there is a mammographic appearance which is highly suggestive of malignancy, action should be taken.

BIRADS VI: known biopsy proven malignancy

The vast majority of mammograms fall into BIRADS I or II.

Risk of Cancer:

BIRADS III: ~ 2%

BIRADS IV: ~ 30%

BIRADS V : 95%

Mammography and Ultrasound Lexicon

BI-RADS Assessment Categories

Breast Composition

Breast Composition

SHAPE

The shape of a mass is either round, oval or irregular.

Always make sure that a mass that is found on physical examination is

the same as the mass that is found with mammography or ultrasound.

Location and size should be applied in any lesion, that must undergo

biopsy.

MARGIN

The margin of a lesion can be:

> Circumscribed (historically well-defined).This is a benign finding.

> Obscured or partially obscured, when the margin is hidden by

superimposed fibroglandular tissue. Ultrasound can be helpful to define the

margin better.

> Microlobulated: This implies a suspicious finding.

> Indistinct (historically ill-defined).

This is also a suspicious finding.

> Spiculated with radiating lines from the mass is a very suspicious finding.

DENSITY

The density of a mass is related to the expected attenuation of an

equal volume of fibroglandular tissue.

High density is associated with malignancy.

It is extremely rare for breast cancer to be low density.

Architectural distortion

The term architectural distortion is used, when the normal

architecture is distorted with no definite mass visible.

This includes thin straight lines or spiculations radiating

from a point, and focal retraction, distortion or

straightening at the edges of the parenchyma.

The differential diagnosis is scar tissue or carcinoma.

Architectural distortion can also be seen as an

associated feature.

For instance if there is a mass that causes architectural

distortion, the likelihood of malignancy is greater than in

the case of a mass without distortion.

Architectural distortion

Asymmetries

Findings that represent unilateral deposits of

fibroglandular tissue not conforming to the definition of a

mass.

Asymmetry as an area of fibroglandular tissue visible on

only one mammographic projection, mostly caused by

superimposition of normal breast tissue.

Focal asymmetry visible on two projections, hence a

real finding rather than superposition.

This has to be differentiated from a mass.

Global asymmetry consisting of an asymmetry over at

least one quarter of the breast and is usually a normal

variant.

Developing asymmetry new, larger and more

conspicuous than on a previous examination.

CALCIFICATIONS

Typically Benign

Skin, vascular, coarse, large rodlike, round or

punctate (< 1mm), rim, dystrophic, milk of calcium

and suture calcifications are typically benign.

There is one exception of the rule: an isolated group

of punctuate calcifications that is new, increasing,

linear, or segmental in distribution, or adjacent to a

known cancer can be assigned as probably benign

or suspicious.

Calcifications of Suspicious Morphology

Amorphous (BI-RADS 4B)So small and/or hazy in appearance that a more specific particle shape cannot be determined.

Coarse heterogeneous (BI-RADS 4B)Irregular, conspicuous calcifications that are generally between 0,5 mm and 1 mm and tend to coalesce but are smaller than dystrophic calcifications.

Fine pleomorphic (BI-RADS 4C)Usually more conspicuous than amorphous forms and are seen to have discrete shapes, without fine linear and linear branching forms, usually < 0,5 mm.

Fine linear or fine-linear branching (BI-RADS 4C)Thin, linear irregular calcifications, may be discontinuous, occasionally branching forms can be seen, usually < 0,5 mm.

Associated features

Associated features are things that are seen in

association with suspicious findings like masses,

asymmetries and calcifications.

Associated features play a role in the final

assessment.

For instance a BI-RADS 4-mass could get a BI-

RADS 5 assessment if seen in association with skin

retraction.

• BENIGN BREAST LESIONS

Lesions of the Major Ducts

Large Duct Papilloma (Intraductal Papilloma)

Papilloma is a benign mass lesion that results from proliferation of the

ductal epithelium that projects into the lumen of the duct.

These lesions are connected by a fibrovascular stalk to the epithelial

lining.

Papillomas may show areas of necrosis, haemorrhage and

occasionally calcification.

The duct around them can dilate forming a cystic structure giving the

appearance of an “intracystic papilloma”.

Benign papilloma is the single most common cause of serous or

bloody discharge from the nipple.

Almost all of these lesions are located in the major subareolar ducts

and are usually single

• Mammography: Often, the lesion is only a

few millimetres in size and the

mammogram is normal.

• A dilated duct may be the only finding. If

the papilloma reaches sufficient size, an

elongated mass will be seen.

• Occasionally mulberry-like calcification

may be seen in the subareolar region

Subareolar mass lesion with dilated

duct extending from the region of the

mass deep into the breast

US shows a grossly dilated duct with

large oval intraductal hypoechoic mass.

Ductogram reveals ductal dilatation with obstruction of the duct with a meniscus

(arrow).

• US plays a major role in the diagnosis.

• In a patient with nipple discharge and a negative mammogram, US

often detects a dilated duct with intraductal solid homogeneously

hypoechoic mass.

• Colour Doppler may demonstrate the vascular stalk.

• Ductography may show intraluminal filling defect, dilatation of the

duct or complete obstruction of a duct with a meniscus.

• On MRI, large papillomas behave similar to fibroadenomas

DUCT ECTASIA Duct ectasia primarily affects the major ducts in the subareolar region.

There is non-specific dilatation of one or more ducts.

The distended ducts are filled with fluid or thick secretions and cellular

debris.

Periductal fibrosis/inflammatory infiltrate usually may be found.

Normal ducts are usually too small to be resolved by mammography.

Ectatic ducts with thickened walls or periductal fibrosis become more

visible.

Dilated, thickened ducts are relatively common, and when symmetrically

distributed, are of no concern.

Intraluminal debris may calcify and produce calcifications called secretory

deposits

US reveals dilated ducts with varying echogenicity of the internal

contents –ranging from anechoic to echogenic depending on the

composition of the contents

FIBROADENOMA

Most common benign tumour of the breast in women of child bearing

age.

Fibroadenoma is essentially the result of overgrowth of the stromal

connective tissue within the lobule.

This idiopathic proliferation of collagen expands the lobule while

simultaneously surrounding an.

Physical examination reveals a firm, mobile, non-tender mass.

Fibroadenomas are hormone dependent lesions.

They regress with age and necrosis within the tumour results in coarse

nodular calcifications compressing the acini and terminal ducts.

Carcinoma is reported in less than 0.5 per cent of fibroadenomas.

Although fibroadenomas are not premalignant lesions, carcinomas can

incidentally arise alongside a fibroadenoma and envelope the lesion.

Also, because there is epithelium within fibroadenoma, cancer can

develop just as it can in normal ductal epithelium, and this is not a

malignant transformation of the lesion.

Hence ill-defined margins, microcalcification and large size or an

increase in size of a fibroadenoma should arouse concern

• On mammography, fibroadenoma is seen as a well-defined, homogeneous round

or oval mass with smooth margins.

• Fibroadenomas may have somewhat flattened contours which if present help to

distinguish them from cysts.

• fibroadenomas follow the structure of the lobule, their margins are often

lobulated.

• Occasionally they have microlobulated margins.

• In the presence of microlobulation however cancer should be suspected.

• The calcification of fibroadenoma can be differentiated from that of carcinoma by

its density, architecture and location

On ultrasonography, fibroadenomas are typically solid, ovoid, well-

circumscribed, homogeneously hypoechoic lesions that are wider

than they are high, with margins that are usually sharply

demarcated from the surrounding tissue.

As with other masses that are round or oval, fibroadenomas may

exhibit lateral wall refractive shadowing.

Posterior acoustic enhancement is frequently seen particularly when

the adenoma is cellular.

Fibroadenomas can however produce varying sonographic

appearances including ill defined margins and posterior acoustic

shadowing in more fibrotic adenomas simulating malignancy.

On Doppler imaging fibroadenomas are either avascular or display

minimal to moderate vascularity (in 20% cases).

Fibroadenoma (cellular/adenomatous

type) (A) T1WI showing a hypointense

focal lesion

The lesion appears bright on STIR image

• MRI is only useful in the diagnosis of sclerosed lesions, i.e. predominantly

fibrous fibroadenomas.

• Such tumours are hypointense on all sequences and show no enhancement.

• Fibroadenomas, which are cellular and contain a fair amount of adenomatous or

myxoid tissue, show an intermediate to high-signal intensity on T2-weighted

images and most have well-circumscribed contours with low intensity internal

septae.

• The enhancement is significant and usually delayed, with absence of washout or

rim enhancement.

• The septi do not enhance. Because fibroadenomas develop multiple lobules,

different lobulations may develop different characteristics.

• Some can be oedematous, whereas others may be hyalinised. These criteria,

however, are not useful in differentiating cellular fibroadenomas from malignant

tumours.

• Hence, needle biopsy is more cost effective for their characterisation and MRI is

not recommended for a mammographically well-defined lesion suspected to be

a fibroadenoma in a premenopausal woman

PHYLLODES TUMOUR A rare tumour of fibroepithelial origin.

It is likely a variant of the benign fibroadenoma.

The basic histological features suggest a fibroadenoma with added branching

cystic cleft-like spaces of myxoid fluid and monotonous cellular stroma giving

a sarcomatous appearance.

The term “cystosarcoma phylloides” is a misnomer because most of these

tumours are benign and only a small percentage becomes malignant.

Approximately 25 per cent recur locally if not completely excised, and as

many as 10 per cent may metastasise to lung or bone.

Recurrence or metastases indicates presence of malignancy. Histological

establishment of malignancy is unreliable.1,14

• Presents as a well circumscribed mass

in relatively young females (mean age

about 45 years).

• It may be of any size and may fill up

most of the breast. It has smooth,

lobulated contours and remains

relatively mobile even when very large.

• Mammographically, the tumour

resembles a large lobulated

fibroadenoma, some part of the margin

may be irregular suggesting local

breast invasion .

• Ultrasonography shows a mass with

very even internal echoes like

fibroadenoma but may show the

additional features of fluid clefts.

• On Doppler examination these lesions

show increased vascularity with high

peak systolic velocity and RI

resembling malignant masses.

As with mammography, they are

typically seen as oval, round, or

lobulated masses with circumscribed

margins. Signal characteristics can

vary with histological grade but in

general are:

T1: usually of low signal

T2: can be variable ranging from

homogenous low to high signal

T1 C+ (Gd): the solid components

enhance after contrast administration

Dynamic contrast: the kinetic curve

pattern can be gradual slow or have

rapid enhancement

Inhomogeneous signal may rarely

result in the context of accompanying

haemorrhage or cystic spaces 9.

Some suggest inhomogeneous signal

as indicative of benignity

CYSTS

Breast cysts develop when lumina of ducts or acini become dilated and

lined by atrophic epithelium.

Simple cysts are common lesions and vary in size from microscopic to

larger palpable masses.

They are usually bilateral and multiple but only one may be identified

clinically or by imaging.

Cysts are common in perimenopausal age but may be seen in women of

all ages.

Cysts are benign lesions, with intracystic cancer found in < 0.2 per cent of

cysts.

Intracystic tumours if present are commonly intracystic papillomas.

Cysts may remain stable for many years or spontaneously resorb.

On mammography-A cyst is a homogeneous, well-defined mass, denser

than the surrounding more atrophic glandular tissue (in perimenopausal age).

The cyst may be of variable size, solitary or may occur in clumps.

Borders are smooth, but may appear lobulated when clumps of cysts are

present.

Calcification is infrequent, may be seen as a thin peripheral rim or flecks of

calcium near the periphery.

Rarely microcysts may contain milk of calcium fluid which on erect lateral

mammography layers on the cyst floor forming so-called “tea-cup”

calcification.

Cysts cannot be accurately diagnosed by mammography, because they

cannot be distinguished from other well-circumscribed masses unless they

display characteristic pattern of calcification

Ultrasonography has a very important role in the

diagnosis,therapeutic aspiration and follow-up of breast cysts.

Cysts should be sharply marginated, anechoic with posterior acoustic

enhancement.

Internal echoes if present should not be ignored.

Solid lesions, including cancer, may have only subtle internal echoes

and be otherwise indistinguishable from cysts. However internal debris

may be seen floating within the cyst.

Posterior enhancement may not be seen if the cyst is small or close to

the chest wall

Complex cyst

When internal echoes or

debris are seen, the cyst

is called a complex cyst.

These internal echoes

may be caused by

floating cholesterol

crystals, pus, blood or

milk of calcium crystals

Galactocele

Cyst with inspissated milk.

It occurs during pregnancy or lactation and may persist long after cessation

of lactation.

It may be unilateral or bilateral or may present with multiple palpable

masses.

Mammographic features vary with fat content of the cyst.

It may be a well-defined dense lesion like a cyst, a radiolucent mass with a

thin wall, or there may be fat fluid level on erect lateral view.

The usual site is the retroareolar central breast area. US shows features of a

cyst or a solid mass with posterior enhancement

LIPOMA

As fat is frequently the preponderant tissue in the breast, it is difficult

to differentiate a true lipoma from normal fat.

Superficial and always encapsulated.

Freely movable and generally soft.

Liposarcoma is a rare lesion. Clinically it is firm and radiographically

dense, and hence is not confused with a lipoma.

On mammography- typical radiolucent appearance with a thin

capsule.

Harder, round, lucent lesions are generally either posttraumatic oil

cysts secondary to fat necrosis or galactoceles.

On US, lipoma are hypoechoic, and similar in echotexture to subcutaneous

fat. They may be distinguished from subcutaneous fat by the presence of

specular reflection from the capsule. Calcification may occur in necrotic

areas

MASTITIS/ABSCESS Breast infections may be in the form of acute mastitis

associated with lactation or a breast abscess.

Acute mastitis may progress to form an abscess.

Patient presents with painful localised or diffuse enlargement of the breast, with erythematous and oedematous overlying skin.

Mammography is seldom performed in acute mastitis.

If there is an underlying abscess formation, it may easily be missed through dense breast.

Abscess is usually well to ill-defined with a spiculatedmargin and overlying skin thickening is often present.

US reveals a complex irregular mass with solid/cystic

component.

CARCINOMA BREAST

Worldwide, breast cancer is the most common

invasive cancer in women.Breast cancer comprises

22.9% of invasive cancers in women and 16% of all

female cancers.

In 2012, it comprised 25.2% of cancers diagnosed in

women, making it the most common female cancer.]

GLOBAL TREND OF BREAST CANCER

The incidence of breast cancer in women has continued to rise. The

rate of increase has slowed recently, however, with the exception of

in situ breast cancer. Breast cancer death rates have decreased

since the early 1990s, with decreases of 2.5% per year among white

women.

Decreased breast cancer deaths have been attributed in part to

breast cancer screening, adjuvant chemotherapy, and

adoption of healthy standard of living

Randomized, population- controlled breast cancer screening trials

using mammography have shown an approximately 30% reduction in

breast cancer deaths in the women invited to screening compared to

women in the control group.

Because of this data, the American Cancer Society recommends

annual screening mammography for women age 40 years and older.

Risk Factors

Female

Older age

Family History

Early menarche

Late menopause

Nulliparity

First birth after age 30

Atypical ductal hyperplasia

BRCA1, BRCA2

Radiation exposure

Signs and Symptoms of Breast Cancer

Breast lump

Nipple discharge (new and spontaneous)

Bloody

Serosanguineous

Serous but copious

New nipple inversion

Skin retraction or tethering

Peau d’orange

Nothing (cancer detected on screening

mammography)

DUCTAL CARCINOMA IN SITU (DCIS)

The pathological classification of DCIS is based on the nuclear grade of the tumour cells (low, intermediate, or high), the architectural pattern of tumourgrowth (solid, papillary, micropapillary, or cribriform), and the presence or absence of comedonecrosis.

Ductal carcinoma in situ originates in a single glandular structure but may spread within the breast through the ductal system.

Two thirds of patients with low-to-intermediate grade ductal carcinoma in situ have multifocal disease, characterised by discontinuous intraductalgrowth.

In contrast, high-grade lesions tend to be continuous.

Most patients are asymptomatic, some may present with nipple discharge or palpable mass.

Currently, nearly 90 per cent of ductal carcinomas in situ are diagnosed while they are clinically occult because of mammographic detection of microcalcifications (in 76% of cases), soft-tissue densities (11%), or both (13%).

Mammography - clusters of pleomorphic, ductally oriented microcalcifications

in majority of the cases.

Less commonly DCIS can produce a mass with ill-defined or lobulated borders

with or without calcification. It may present as only architectural distortion.

Microcalcifications in the breast are frequently evaluated by stereotactic core

needle biopsy.

PAGET’S DISEASE Centrally located ductal carcinoma grows along the ducts into the

nipple with distinct morphological changes of the epithelial cells at the

summit of the nipple (pagetoid changes).

This forms 2 per cent of the total number of operable breast cancers.

The clinical features include mild itching to extensive changes of the

nipple and surrounding area.

Scaling may progress to erosion, saucer-like ulceration or crevices in

the nipple. Erosion extends to the areola and may cover a larger area

of the skin.

Fifty per cent patients have a palpable mass. This disease is usually

unilateral.

On Mammography-nipple and areolar thickening is present.

A subareolar mass may or may not be seen.

Malignant type of calcification may be seen extending from deeper carcinoma to the nipple.

Paget’s disease is not well delineated on US. The underlying mass may be seen on US with features similar to any other malignant lesio

LYPMHOMA

Lymphoma of the breast can occur primarily or as a

metastatic lesion from elsewhere in the body.

Primary lymphoma is rare accounting for only 0.1 per

cent of breast malignancy

Mammary lymphoma may produce a single discrete

nodule or multiple nodules.

It may also produce a diffuse increase in radiographic

density.

Nodules may be well-defined or illdefined but spiculations

are not a feature of lymphoma.

Presence of large axillary nodes should raise the

possibility of lymphoma

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