Imaging of the Breast

Female breasts, made of glandular, adipose, and connective tissue, are hormone-sensitive organs that undergo
changes along with the menstrual cycle and during pregnancy. Breasts may be affected by various diseases, in which
different imaging methods are important to arrive at the correct diagnosis and management. Mammography is used
for breast cancer screening and diagnostic evaluation of various breast-related symptoms. Ultrasonography is rarely
used for screening, but it is typically used for diagnostic workup and during procedures (e.g., breast biopsy). MRI of
the breasts is used as a supplementary screening tool for those at high risk for developing breast cancer. Additionally,
in individuals with breast implants, inconclusive mammographic and/or breast ultrasound findings, and diagnosed
breast cancer needing evaluation pretreatment and posttreatment, MRI is an important breast radiologic tool.

Last updated: February 14, 2023

CONTENTS

Mammography
Breast Ultrasound
Breast MRI
Abnormal Findings
References

Mammography
Mammogram
Film-screen mammogram: uses X-rays, radiographic film and intensifying screens to produce an image of the
breasts
Digital mammogram: a digital detector takes the place of the film and screen

Indications
 Screening:
All women ≥ 40 years of age are recommended to undergo mammography for early detection of
breast cancer or precancerous lesions.
Frequency recommendations vary with medical organizations.
High-risk individuals (e.g., calculated lifetime risk of breast cancer > 20%) by age 30, are recommended to
have:
An annual mammogram, AND
Breast MRI (typically alternating every 6 months between the 2)
Diagnostic mammogram:
Evaluation of palpable mass in women > 30 years of age
Abnormality found on routine screening mammogram
Evaluation of women presenting with breast pain or tenderness, nipple discharge, skin and nipple
changes

Contraindications
There are no absolute contraindications, but there are relative ones (owing to adverse effects of radiation
exposure).
Pregnancy (mammography can be postponed if individual is asymptomatic and has average risk for
breast cancer)
Lactation:
Lobules attenuate X-rays, thus increasing the density of the breasts
Visualization of lesions will be difficult.
Women < 30 years of age: increased sensitivity to radiation

Mammogram views
Table: Mammogram views

Views Description

Standard Mediolateral oblique Better view of the superior lateral quadrant of the
views (MLO) view breast and axilla

Craniocaudal view (CC) Medial part of the breast: lower part of image
Lateral part of the breast: upper part of image

Specialized Spot compression Better visualization of suspicious masses,

views calcifications, or asymmetric breast tissue

Magnification

XCCL (exaggerated CC Modified CC view, focused on the lateral part of

lateral) view breast

XCCM (exaggerated CC Modified CC view, focused on the medial part of

medial) view the breast

Normal findings
 Normal breast is composed of:
Parenchyma (ducts and lobules)
Connective tissue
Fat
Breast findings:
Brighter signal represents fibroglandular tissue.
Gray areas represent adipose tissue.
Breast density:
Findings can be:
Extremely dense (which can obscure lesions or cancers)
Heterogeneously dense
Scattered fibroglandular
Almost entirely fatty
Young women typically have denser breast tissue.
Older women have a higher amount of fatty tissue.

Mammographic assessment categories

Table: Mammographic assessment categories

Category Assessment Follow-up

BI-RADS Incomplete assessment Additional mammography views or ultrasound follow-

0 up needed

BI-RADS 1 Negative Continue with routine screening

BI-RADS Benign findings Continue with routine screening

2

BI-RADS Probably benign findings Diagnostic mammography or ultrasound in 6 months

3

BI-RADS Suspicious abnormality Biopsy should be considered.

4

BI-RADS Highly suggestive of Biopsy should be performed.

5 malignancy

BI-RADS Biopsy-proven malignancy Management for breast cancer

6

BI-RADS: Breast Imaging Reporting and Data System

Breast Ultrasound
Indications
Evaluation of any palpable finding (ideal initial study for women who are < 30 years of age, pregnant, or lactating)
Further evaluation of abnormal masses found during mammography or MRI scans
Method for guidance for biopsy of breast tissue
Assessment of the axillary, supraclavicular, and infraclavicular lymph nodes in cases of suspicion of breast cancer
Can infrequently be used as an adjunct to screening in women with dense breast tissue

Normal findings
Young nonlactating breast:
Mainly composed of echogenic fibroglandular tissue, with little to no fat
Greater amounts of adipose tissue are deposited with increasing age/parity.
Lactating breast: prominent fluid-filled ducts with echogenic epithelial lining
Breast MRI
MRI of the breasts
Radiologic technique that uses magnetic fields and radiofrequency pulses to produce highly detailed images of
the breasts.

Indications
Screening:
Indicated as supplementary screening along with mammography in women with a high risk of
breast cancer
BRCA1 or BRCA2 mutations
Strong family history of breast and/or ovarian cancer
History of radiation therapy to the chest (e.g., for Hodgkin lymphoma)
Used as follow-up for an abnormal or inconclusive mammography result
Detection of occult breast cancer in an individual presenting with axillary lymph nodes diagnosed with metastatic
disease
In diagnosed breast cancer, MRI aids in preoperative evaluation and staging, as well as in measurement of
response to chemotherapy.
Evaluation of breast implants
Evaluation of inconclusive mammograms or ultrasounds
In cases of dense breast tissue, which hinders other tests

Contraindications
A breast MRI is contraindicated in MRI-incompatible hardware or anaphylaxis to gadolinium.

MRI findings
Findings are grouped into 3 categories:
Focus/foci: area of enhancement measuring < 5 mm in diameter
Mass:
A lesion that occupies a space within the breast
The shape, margins, and enhancement pattern of the mass are of special diagnostic value.
Benign lesions often show progressive enhancement.
Among the findings seen in malignancy:
Masses with irregular or spiculated margins
Rapid uptake and washout of gadolinium
Non–mass-like enhancement:
Areas of enhancement without a detectable 3-dimensional mass
Distribution can be diffuse, regional, segmental, or linear.
Enhancement can vary: heterogeneous, homogeneous, clumped, or clustered

Abnormal Findings
Breast cysts
Ultrasonography findings:
Simple cyst:
Well-defined round/oval lesion
No internal echo (anechoic)
Thin, regular walls
Posterior acoustic enhancement
Complex cyst:
Presence of internal echoes caused by accumulation of pus, blood, or milk
Absence of posterior wall enhancement
Chronic cysts may be ill defined.
Mammography findings:
Oval or spherical shape
Smooth, well-defined borders

Fibrocystic changes
Ultrasonography findings (highly variable):
Focal areas of thickening (patchy increase in echogenicity)
Single cysts or clusters of small cysts
Mammography findings:
Heterogeneous and usually dense parenchyma
Partially circumscribed masses
Tea-cup, low-density round calcifications
Fibroadenoma
Ultrasonography findings:
Well-defined spherical lesion
Smooth borders (capsule)
Uniform hypoechogenicity
May or may not present with internal echoes
Transverse diameter > anteroposterior diameter (insinuating that it does not invade through fascial
planes)
Mammography findings:
Well-circumscribed oval or spherical mass
Smooth, regular borders
Hypodense or isodense to glandular tissue
May present with lobulations
Popcorn-shaped calcifications (in involuting fibroadenomas)
Lipoma
Ultrasonography findings:
Well-defined echogenic lesion
Soft consistency; can be deformed by compression with the transducer
Lamellar appearance and thin capsule
Mammography findings:
Radiolucent mass with no calcification
May have a thin, peripheral, fluid density capsule
Ultrasound image of a well-defined subtly echogenic mass (lipoma) with a lamellar pattern and a well-defined, thin capsule (arrows)

Image: “Lipoma” by Gokhale, S. License: CC BY 2.0

Breast cancer
Ultrasonographic characteristics of malignant lesions:
Usually hypoechoic
Ill-defined or irregular borders
Anteroposterior diameter > transverse diameter (insinuating that it does invade through fascial planes)
Spiculated margins
Posterior acoustic shadowing
Microcalcifications
Significant vascularity seen on Doppler imaging
Mammography:
Characteristics of benign breast masses:
Well-defined, circumscribed mass
Radiolucent ring surrounding the lesion (halo sign)
Diffuse microcalcifications
Presence of fat in a mass
Characteristics of malignant lesions:
Hyperdense masses
Fine linear branching microcalcifications
Irregular borders
Spiculation
Architectural distortions
MRI findings:
Irregular borders
Spiculations
Segmental distribution and calcifications
Enhancing internal septations
Perilesional edema: clustered ring enhancement
Heterogeneously enhancing pattern
Fat necrosis
Ultrasonograpy findings:
Hypoechoic mass with well-defined margins
May or may not have mural nodule(s)
Can produce significant shadowing secondary to coarse calcifications
Mammography findings:
May present as an ill-defined, irregular, spiculated mass (similar to breast cancer)
Oil cysts
May appear with egg-shell calcifications
Breast hamartoma
 Benign slow-growing breast lesion (uncommon)
Contains fat and fibrous tissue and presents as painless masses
Ultrasonography findings:
Margins are difficult to detect because it resembles normal breast tissue.
May present with internal echoes that are a mix of hyperechoic and hypoechoic components
Mammography findings:
Well-circumscribed spherical or oval compressible mass with thin capsules
Heterogeneous: contains both fat and soft-tissue internal densities

Mammogram showing a fat-containing oval mass, suggestive of hamartoma

Image: “A 26-year-old pregnant female with a new palpable mass” by Ojeda-Fournier H, Nguyen JQ. License: CC BY 2.0

References
1. Aydin, H. (2019). The MRI characteristics of non-mass enhancement lesions of the breast: associations with malignancy. Br J Radiol
92:20180464. https://doi.org/10.1259/bjr.20180464

2. Farrokh, D., Hashemi, J., Ansaripour, E. (2011). Breast hamartoma: mammographic findings. Iran J Radiol 8:258–260.
https://doi.org/10.5812/iranjradiol.4492

3. Freimanis, R.I., Ayoub, J.S. (2011). Radiology of the breast. Chapter 5 of Chen, M.M., Pope, T.L., Ott, D.J. (Eds.), Basic Radiology, 2nd ed.
McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=360&sectionid=39669012

4. Reeves, R.A., Kaufman, T. (2021). Mammography. StatPearls. Retrieved November 23, 2021, from
https://www.ncbi.nlm.nih.gov/books/NBK559310/

5. Slanetz, P. (2021). MRI of the breasts and emerging technologies. UpToDate. Retrieved December 11, 2021, from
https://www.uptodate.com/contents/mri-of-the-breast-and-emerging-technologies

6. Tozaki, M., Igarashi, T., Fukuda, K. (2006). Breast MRI using the VIBE sequence: clustered ring enhancement in the differential diagnosis
of lesions showing non-masslike enhancement. AJR Am J Roentgenol 187:313–321. https://pubmed.ncbi.nlm.nih.gov/16861532/