1. Mammography Cases 1-12

2. Case directory 1 2 3 4 5 6 7 8 9 10 11 12

3. Case 1

5. Silicone injection
Innumerable high density rim-calcified masses are seen, characteristic of silicone granulomas

6. Breast implant
Retropectoral, single lumen implant containing high density silicone

7. Breast implant Single lumen, subglandular implants
Capsular contracture in left breast implant  lost normal tear-drop shape

8. Case directory
Saline breast implant

9. Case 2

10. Gynecomastia
Proliferation of fibroglandular tissues resulting in breast enlargement
Hyperplasia of the ductal elements, fibroepithelium, and stroma (lobules do NOT develop)
Dense tissues fan out from retroareolar region rather than forming a mass
Bimodal age distribution: MC puberty, 5th decade

11. Gynecomastia Etiology: excessive estrogens or deficient androgens
Case directory
Gynecomastia
Etiology: excessive estrogens or deficient androgens
Idiopathic
Physiologic: newborn, puberty, senescence
Pathologic: Klinefelter's syndrome, congenital adrenal hyperplasia, adrenal neoplasms, testicular tumors, paraneoplastic syndromes, liver failure, thyrotoxicosis, testicular failure
Drugs: cannabinoids, psychotropics, antihypertensives (reserpine, spironolactone), digitalis, cimetedine, hormonal (estrogens, HCG, antiandrogens)
No increased risk for male breast cancer
Male breast cancer presents at a later stage so worse prognosis at presentation

12. Case 3

16. Radial scar Case findings:
7 mm density in retroareolar location in the left breast, with radiating linear strands surrounding it
Best seen on the CC view
Spiculated lesion, central nidus with internal radiolucencies (white star)
Predominantly radiolucent spiculations (rather than radiodense)
Requires open surgical biopsy  malignancy present in 25% of cases (some are invasive carcinomas, but others are radial scars that have small internal or adjacent areas of carcinoma)
Open surgical biopsy: less subject to sampling error than are percutaneous biopsy procedures (aspiration or core biopsy)

17. Spiculated lesion Malignant: Benign:
Case directory
Spiculated lesion
Malignant:
MC invasive ductal (90%), invasive lobular (10%)
Malignant spicules: extend in all directions from a central tumor mass
Benign:
MC radial scar, sclerosing adenosis
Post-surgical scar: change in shape and density on different projections, contain central lucency, and regress over time, follow-up within 6 months
Benign spicules: bundled in parallel

18. Case 4

20. Hamartoma (lipofibroadenoma, fibroadenolipoma)
Uncommon benign breast tumor
Composed of lipid, glandular, and fibrous tissues
May appear encapsulated, but does not possess a true capsule
Surrounded by a thin layer of fibrous tissue
Cut sausage and breast within a breast: terms used to describe the classic mammographic appearance of a breast hamartoma

21. Hamartoma (lipofibroadenoma, fibroadenolipoma)

22. Hamartoma (lipofibroadenoma, fibroadenolipoma)
Case directory
Hamartoma (lipofibroadenoma, fibroadenolipoma)

23. Case 5

26. Sebaceous cyst (epidermal inclusion cyst)
Case directory
Sebaceous cyst (epidermal inclusion cyst)
Round, smoothly bordered mass that often abuts the skin surface
Mass projects into the subcutaneous tissues rather than out from the skin surface
Tangential view of the mass demonstrates that it is located within the skin

27. Case 6

29. Case directory
Neurofibromatosis

30. Case 7

32. Case directory
Lipoma
Case findings:
very thin radiopaque border surrounding the mass is its fibrous capsule
BI-RADS 2: mass is fatty in density, and therefore benign
Fat containing mass, circumscribed radiolucent mass, with a thin capsule
Encapsulated mature adipose tissue
Soft lesion: can grow to substantial size before they become palpable
Can calcify, either within the capsule, or within the mass itself if there is central infarction
MC seen in postmenopausal women

33. Case 8

35. Filariasis Case findings:
Mammograms showed unusual serpiginous, tubular-wormlike calcifications without an accompanying mass
Serpiginous calcifications represent calcified degenerating parasite tissue (filarial granulomas of the breast)
Parasite: Wuchereria bancrofti, Brugia malayi

36. Ultrasound of right breast
Case directory
Case 9
Ultrasound of right breast

38. Phylloides tumor (cystosarcoma phyllodes)
Case findings:
US: multiple solids, hyperechoic nodules with central cystic components
CT: well-circumscribed tumor without obvious enhancement
Age: 45 years-old
Features:
Circumscribed round, oval or lobulated tumor, sometimes with partly indistinct borders
No spiculation on mammography
US: circumscribed hypoechoic lesions with varying degrees of inhomogeneity and small cystic spaces

39. Phylloides tumor (cystosarcoma phyllodes)
Differentiation between benign and malignant phyllodes tumors is not possible on imaging
Locally invasive tumor which rarely metastasizes
DDX rapidly enlarging masses:
Phylloides tumor
Juvenile giant fibroadenoma
Abscess
Hematoma

40. Phylloides tumor (cystosarcoma phyllodes)
Predominantly circumscribed malignant phyllodes tumor

41. Phylloides tumor (cystosarcoma phyllodes)
US: smooth margined lobulated noncompressible lesion with internal cystic spaces and varying echogenicity

42. Phylloides tumor (cystosarcoma phyllodes)
Case directory
Phylloides tumor (cystosarcoma phyllodes)

43. Case 10 Benign microcalcification Plasma cell mastitis
(secretory calcifications)
Fat necrosis

44. Benign calcifications
Fibroadenoma
Vascular
Benign calcifications

45. Benign calcification Case directory
(a) Punctate: small grains of calcium, round, regular, dense, fairly equal in size, benign microcalcification
(b) Linear: long, dense, smooth, calcifications, outlining the ductal system, usually the result of ductal inflammatory changes
(c) Spherical: round or oval, having lucent centers, may be the result of fat necrosis as exemplified here, but may also represent small calcified cysts
(d) Coarse (popcorn): large, irregular, very high density, pathognomonic for calcified fibroadenoma
(e) Cylindrical: calcium deposits within walls of tubular structures might be vascular as illustrated here or past periductal inflammatory changes
(f) Smooth: dense, round, smoothly bordered, medium sized, isolated, benign grains of calcium

46. Case 11

47. Calcification
(a) Jagged: coarse, dense, large, branching calcium deposits following inflammation or irradiation therapy (dermatomyositis this case)
(b) Heterogeneous: very small < 0.5 mm variable sizes, shapes and densities, highly suspicious (DCIS this case)
(c) Regular: small, dense, round, benign microcalcification located at the periphery of a small calcifying cyst
(d) Branching: heterogeneous microcalcification, filling the ductal system with its dichotomic distribution, highly suspicious (high grade DCIS, comedo type this case)

48. Skin calcifications, polihedric, annular and dense
Tangential view: show that the calcifications are located in the skin

49. Rod shaped calcifications: stick-like, solid or hollow concretions, sometimes branching, usually the result of previous ductal inflammatory changes
Secretory calcification, or plasma cell mastitis

50. Acinar calcifications are concretions formed within acini of dilated lobules. Calcifications depicted here revealed a foci of lobular hyperplasia

51. Rim calcifications (eggshell): spherical capsules of fibroadenoma or as depicted here, calcified cystic capsules

52. Milk of calcium: precipitated amorphous calcium particles, floating within a cyst as seen on the left picture
True lateral position: particles may show the “tea cup” phenomenon as illustrated on the right

53. Suture calcification: knot-like, calcium deposits on suture materials seen in a postoperative, post-irradiated breast

54. Case directory
Heterogeneous calcification: variable shape, variable size and variable density, may might show a branching pattern and are usually arranged in clusters or distributed according to the segmental partition of the breast (comedocarcinoma these 2 cases)

55. Case 12

56. Rheumatoid arthritis Case findings:
Enlarged dense axillary lymph nodes
DDX of enlarged axillary lymph nodes:
BCA with lymph node metastasis
Lymphoma
HIV RA
TB, sarcoidosis
Benign reactive nodal hyperplasia

57. Metallic deposits in axillary nodes from RA gold injections

58. Rheumatoid arthritis DDX of calcified axillary lymph nodes:
Case directory
Rheumatoid arthritis
DDX of calcified axillary lymph nodes:
MC metastasis (ovarian, mucinous tumors)
RA with gold treatment
Treated lymphoma