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MAMMOGRAPHY
BreastDemonstration data

Diagnostic Mammography + Tomosynthesis

Diagnostic mammography is the targeted evaluation of a symptomatic breast or of a finding recalled from screening. It combines standard projections with problem-solving views such as spot compression and magnification, and increasingly with digital breast tomosynthesis (DBT), which reduces tissue overlap and improves lesion characterisation. Findings are described and managed using the BI-RADS lexicon and assessment categories.

Indications

  • Palpable breast lump or focal area of clinical concern
  • Workup of an abnormality recalled from screening mammography
  • Focal, non-cyclical breast pain or skin and nipple changes
  • Spontaneous single-duct or bloody nipple discharge
  • Short-interval follow-up of a probably benign lesion and surveillance of treated breast cancer

Contraindications & Cautions

  • Pregnancy is a relative consideration; diagnostic mammography may still be performed with shielding when clinically necessary, often after ultrasound
  • No absolute contraindication in symptomatic patients where benefit outweighs the low dose
  • Ultrasound is preferred as the first test in women under about 30 and during lactation
  • Recent breast surgery or infection may limit compression tolerance

Patient Preparation

  • Take a focused history of symptoms, prior surgery, hormone use and family history
  • Mark palpable lumps, scars and the area of concern with a radiopaque skin marker
  • Advise avoiding deodorant, powder or lotion that can mimic calcifications
  • Retrieve prior mammograms for comparison
  • Explain compression and its role in reducing dose and motion

Technique & Parameters

  • Standard craniocaudal (CC) and mediolateral oblique (MLO) projections of the symptomatic breast
  • Digital breast tomosynthesis acquired to reduce overlapping tissue and better define margins
  • Spot compression views to disperse overlapping tissue and confirm or exclude a mass or distortion
  • Magnification views (with spot compression) to characterise the morphology and distribution of calcifications
  • Additional projections (true lateral, rolled CC, exaggerated CC, cleavage) to localise and confirm findings
  • Correlate with targeted ultrasound and proceed to image-guided biopsy for suspicious findings

Systematic Review

  • Compare with prior studies and assess overall breast density
  • Search each view systematically for masses, calcifications, asymmetry and architectural distortion
  • Characterise masses by shape, margin and density
  • Characterise calcifications by morphology and distribution
  • Correlate the mammographic finding with the site of clinical concern and with ultrasound
  • Assign a BI-RADS assessment category and management recommendation

Key Findings & Significance

  • Spiculated high-density mass or architectural distortion suggests invasive carcinoma
  • Fine pleomorphic or fine linear branching calcifications in a segmental or linear distribution suggest DCIS or invasive disease
  • Circumscribed oval mass suggests a benign lesion such as fibroadenoma or cyst (correlate with ultrasound)
  • Coarse popcorn-like calcification is typical of an involuting fibroadenoma
  • A developing or enlarging focal asymmetry warrants further assessment
  • Skin thickening and trabecular coarsening may indicate inflammatory carcinoma or oedema

Differential Considerations

  • Spiculated mass: invasive carcinoma, radial scar, post-surgical scar or fat necrosis
  • Circumscribed mass: cyst, fibroadenoma, phyllodes tumour, or circumscribed carcinoma
  • Suspicious calcifications: DCIS versus fibrocystic change, fat necrosis or fibroadenoma
  • Architectural distortion: carcinoma, radial scar, prior surgery or benign sclerosing lesion
  • Focal asymmetry: summation artefact, fibroglandular tissue, or an underlying mass

Pearls & Pitfalls

  • Tomosynthesis increases cancer detection and reduces recall by unmasking distortion hidden by overlap
  • Magnification views are essential to characterise calcification morphology and extent
  • A palpable lump with negative mammography still requires ultrasound and clinical correlation (triple assessment)
  • Always seek a summation artefact explanation for a focal asymmetry with spot compression before recall
  • Assign an explicit BI-RADS category as it drives the management recommendation

Structured Report

  • State the views and whether tomosynthesis and problem-solving views were performed
  • Report breast density and describe findings using the BI-RADS lexicon
  • Give the location, size and characteristics of any mass, calcifications or distortion
  • Correlate with ultrasound and clinical findings
  • Assign a final BI-RADS category (0-6) with a clear management recommendation such as biopsy or follow-up

References

  • ACR BI-RADS Atlas, 5th Edition (Breast Imaging Reporting and Data System)
  • ACR Practice Parameter for the Performance of Diagnostic Mammography
  • Vedantham S et al. Digital Breast Tomosynthesis: State of the Art. Radiology
  • Sickles EA. Breast Imaging: From 1965 to the Present. Radiology

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.