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Breast Imaging

Breast cancer, imaging

The histopathological patterns (see breast cancer histological classification) are reflected in the imaging characteristics of breast cancer, but it is by no means always possible to predict the histological type from the mammogram or ultrasound examination. From an imaging point of view the following patterns of breast cancer can be identified:

  • spiculated tumour;

  • circumscribed tumour;

  • nonspecific density;

  • architectural distortion;

  • calcifications;

  • oedema of the breast; and

  • unusual presentations.

    Spiculated tumour

    Cancers that provoke a reactive fibrosis have an irregular, serrated or stellate appearance resulting in a characteristic radiographic image (Fig.1). This type of cancer is sometimes referred to as spiculated carcinoma or scirrhous carcinoma. The fibrotic strands undergo shortening with dimpling of the overlying skin or retraction of the nipple depending on the location of the tumour.

    At ultrasonography the spicules cause refraction of the sound waves which is seen as a hyperreflective corona and also causing posterior shadowing (Fig.2).

    Cancer with reactive fibrosis (see desmoplastic reaction) almost always feel larger than their actual size. Sometimes a wide radiolucent zone is seen around the tumour. Most spiculated tumours represent ductal carcinoma, invasive lobular carcinoma or tubular carcinoma (see breast cancer histological classification).

    Circumscribed tumour

    Many ductal carcinomas, as well as mucinous, medullary and papillary carcinoma, usually present as more or less circumscribed tumours. Such cancers may be entirely sharply delineated or may be partly irregular in outline and sometimes have a so-called comet tail (Fig.3, Fig.4).

    Nonspecific density

    Nonspecific density implies a density without tumour traits such as clear delineation or spiculation and without calcifications. Any type of carcinoma when small may appear as a nonspecific density. This applies also to larger tumours when located in dense fibroglandular tissue.

    Architectural distortion

    Architectural distortion may be defined as a disruption of the normal architecture of the breast without dominating mass (see architectural distortion, breast (III:2), Fig. 1). A certain proportion of invasive lobular carcinoma presents in this way histologically corresponding to multiple invasive foci, often mixed with LCIS and with little desmoplastic reaction.

    Calcification

    Malignant calcifications typically vary in size, form and density with a ductal or branching arrangement. Such calcifications are seen with the so-called comedo-type of DCIS and represent dystrophic calcification of necrotic material in the core of a solid intraluminal carcinoma growing in dilated ducts. Sometimes the widened ducts can be seen as soft tissue structures (see calcification, breast (III:2), Fig. 3). Other growth patterns of DCIS such as cribriform and micropapillary or mural, are usually associated with less characteristic calcifications or no calcifications at all (see calcification, breast (III:2), Fig. 4).

    With state-of-the-art high resolution ultrasonography DCIS can sometimes be demonstrated (Fig.5).

    Oedema of the breast

    • If the venolymphatic drainage of the breast is significantly obstructed by angiolymphatic invasion and/or extensive metastatic disease, e.g. in the axilla, the dominant radiographic finding may be signs of oedema of the breast, i.e. skin thickening, a trabecular pattern which may be particularly obvious in the subcutaneous tissue and in addition a generally increased density in the breast tissue (see oedema, of the breast, Fig. 1).

    Unusual presentations

    Papillary carcinoma, invasive and/or noninvasive, may present as a cluster of nodules or as several circumscribed cystlike tumours in one quadrant of the breast (Fig. 6). An extensive tubulonodular pattern without calcifications may occur representing noninvasive papillary or other non-comedo type of carcinoma. Noninvasive carcinoma may provoke a reactive fibrosis and an inflammatory reaction which may appear as a tumour, sometimes even spiculated with or without calcifications (Fig. 7).

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    Fig.1

    Mammogram, mediolateral, oblique view. Ductal breast cancer with productive fibrosis and retraction of the nippleareolar complex, as well as the major pectoral muscle (arrow).
    Breast cancer, imaging, Fig.1
    Breast cancer, imaging, Fig.2
    Breast cancer, imaging, Fig.3
    Breast cancer, imaging, Fig.4
    Breast cancer, imaging, Fig.5
    Breast cancer, imaging, Fig.6
    Breast cancer, imaging, Fig.7