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Let's Test Your Skills

You have to make the finding.

That is the first step in interpreting any radiology exam. Breast imaging is no different. If you can't find the abnormality, you won't be able to make a diagnosis.

The key to detecting subtle breast cancers is performing high quality imaging and having a reproducible search pattern so that findings are not missed.

By now, you should have received your Breast Imaging Starter Kit.  If you still need one, click here to get started.

There are several cases below that highlight the main points covered in the kit. To get the most out of this exercise, take your time and really work on mastering the steps, not just racing to make the finding.

Remember, we are trying to develop a systematic approach to imaging. This is just an initial attempt at developing good habits for evaluating breast imaging exams. Scroll slowly so you don't accidentally reveal the answer.

Practice makes perfect, so let's get started...

Part I - Mammography

Now that you have reviewed the Mammography Starter Kit, you have a step-by-step approach to interpreting a mammogram. It is not the only way to do it, but it is a comprehensive approach that won't miss things. Feel free to tweak the steps as necessary to make the system your own.  

Remember the most important this is to be consistent. Have a system and repeat it every single time you look at a mammogram.  

​Let's get started with the practice cases.

Case 1 
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Case 1 - Normal Exam

Alright, so that was pretty easy.  A normal mammogram composed almost entirely of fat. But we just wanted to get you in the habit of going through the steps.  Checking the "Danger zones" and looking for symmetry.   Remember, even if it seems slow and cumbersome, go through the motions of every step in the system.  I promise you, it will get faster with practice and it will save you from missing a cancer someday!

Case 2
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Case 2 - Danger zone findings

This case has two findings, both residing in "danger zones."  These are areas of the breast that shouldn't typically have much going on.  On the left CC view, there is a small mass containing coarse calcifications in the retroglandular fat. This mass is not visible on the MLO views (as it is too far posterior).  This case highlights why two views are required to ensure that all the breast tissue is evaluated. Fortunately, this mass had been stable for years on prior exams and was a benign fibroadenoma.
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The second finding on this case is a mass in the axillary region of the right breast. You can see this mass along the superior edge of the right MLO view. If you are not looking closely, this mass could be glossed over or confused for an intramammary lymph node. 
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Mass in the axillary region of the right breast requires further evaluation.
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Spot magnification view and an ultrasound demonstrates a spiculated mass in the axillary tail of the right breast.
This spiculated mass in the axillary tail of the right breast was biopsied and revealed a grade 2 invasive ductal carcinoma. Remember to always check the "danger zones" on a mammogram.  And don't get satisfaction of search... there may be more than one finding.

Case 3
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Case 3 - Subtle mass in the retroglandular fat

Another example of the importance of scouring every inch of the mammogram.  Paying extra attention to the "danger zones" will pay off for you on this case as well. There is a very subtle finding in the retroglandular fat of the left breast. The focal asymmetry is visible on both the CC and MLO views.
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The focal asymmetry is more prominent on the tomosynthesis images. Ultrasound evaluation demonstrated an irregular hypoechoic mass in the inferior left breast.
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Ultrasound core biopsy of the suspicious mass revealed grade 2 invasive ductal carcinoma.

Case 4
Here is a magnified shade symmetry of both breasts to help in your search.
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Case 4 - Suspicious calcifications

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One of the things you are looking for when interpreting a mammogram are calcifications. It is important to remember that you are looking for microcalcifications. In general, you don't need to worry about the big chunky macrocalcifications you can see from across the room. Make sure to include a full-field or "magnified" look at both breasts to try and find calcifications... sometimes they can be very subtle. Once you have identified potentially worrisome microcalcifications then special magnified views are performed.
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Magnified CC and ML views of the left breast demonstrate suspicious linear calcifications. Stereotactic biopsy revealed Ductal Carcinoma In-Situ (DCIS).

Case 5
79 year old wheelchair bound female presents for a screening mammogram.


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Case 5 - Technical recall

Obtaining a high-quality mammogram can be very difficult depending on the patient's mobility and body habitus.  When the mammogram has to be performed with the patient seated, it can be very challenging to get a technically perfect evaluation. That being said every effort must be made to tailor the exam and try to cover as much of the breast tissue as possible. The right MLO view above does not show adequate (or any) of the pectoralis muscle. The right MLO exam was repeated and see the impact it had. 
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Repeat right MLO view with better visualization of the pectoralis muscle (and therefore posterior breast tissue) demonstrates a very suspicious spiculated mass. Biopsy ultimately revealed a grade 1 Invasive Ductal Carcinoma.

Case 6
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Case 6 - Inflammatory Breast Cancer

What!!!! You mean you called this mammogram normal.. Don't worry, you are not alone. 

​The findings of inflammatory breast cancer can be very subtle.  The key finding on this exam is the asymmetric skin thickening involving the left breast.  This may be the only sign of inflammatory breast cancer, which is one of the most lethal, rapidly progressing subtypes of breast cancer. 
Without a systematic approach, it is very difficult to appreciate this subtle finding.  However, if a quick focused assessment of the skin is built into your approach to interpretation, you have a shot and making this finding and potentially saving this persons life. It only takes a millisecond longer but can make a world of difference.
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Left MLO view demonstrates diffuse skin thickening. The breast was also slightly enlarged. A breast MRI subtraction image later demonstrated diffuse enhancement and thickening of the skin consistent with inflammatory breast cancer.

How Did You Do?

Did you get them all correct. Making the finding is the most important part of being a good mammographer. If you missed any, don't worry.  Some of these cases were quite challenging.  They were meant to highlight the importance of a systematic approach ensuring that you don't miss a subtle finding. 

If you want to learn more about all aspects of breast imaging, check out our signature Master Breast Imaging training program. You will not find a more comprehensive, practical way to learn. 

Also, stay tuned as you will receive part 2 of our free Breast Imaging Starter Kit in your email inbox in the next few days.  Then you can return to this page and go over the ultrasound section below.

Part II - Breast Ultrasound

I know how to do ultrasound, that's easy.  

Looking for masses in fatty tissue, how hard can it be.  I will just have a sonographer do that.

Breast ultrasound is often overlooked and the nuances underappreciated, even by experienced radiologists.  It is usually glossed over in training programs.  The sad truth is that many radiologists are woefully ill-equipped to interpret, much less perform a high-quality breast ultrasound evaluation.  

How do we fix this.  Step one = You have to scan patients yourself.

This is the most important part of learning breast ultrasound.  It is impossible to adequately interpret breast sonography if you aren't highly skilled at performing the scan yourself.  Your job as a radiologist is not simply to report the findings and measurements that a sonographer discovers.  Your job is to take it the next step.  To truly add value, you need to be able to do quality control, troubleshooting, and most importantly make the diagnosis. 

High Quality Ultrasound

Good breast ultrasound images allow for more specific diagnoses, limit misdiagnoses, and in general are more actionable.

Some features of high quality ultrasound exams include:
  • Appropriate depth - the pectoralis should always be included at the bottom of the image to ensure that breast tissue is not missed. However you don't need to image the heart and lungs during your exam.
  • Appropriate gain - it's all shades of gray, but you don't want your images too dark or too bright.
  • Appropriate equipment - high frequency probes (12 MHz or greater), updated equipment as able, settings optimized for breast imaging.
  • Appropriate technique - the pectoralis muscle should be parallel (not angled), the finding centered on the screen and the recommended images acquired.

Low Quality Ultrasound (Things to Avoid)

It is important to recognize the limitations of breast ultrasound.  By knowing what it can and cannot do, you can avoid making silly mistakes.  ​Below are some example of less than ideal breast ultrasounds.  
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Avoid unnecessary and inaccurate measurements. All they do is waste time and confuse people.
 When you make a finding (mass, cyst, etc), appropriate labeling of the location requires the clock position and approximate distance from the nipple.

Please note the word approximate.  No need to measure the distance from the nipple or depth of a lesion with calipers. This is totally inaccurate. If the patient rolls on their side or shifts position, the measurement and certainly the lesion depth will change.  Save time and just estimate the distance between your probe and the nipple to the nearest centimeter.

Also, please avoid measuring all cysts in 2 or 3 dimensions. It is meaningless. Cysts fluctuate in size over time (due to hormone changes, medications, caffeine, other external factors).  If you measure the same cyst 2 weeks later it will be a different size (or maybe even resolved and no longer present). Don't waste your time. 
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If you adjust the gain and brighten the image to more appropriate levels, this is an obvious suspicious solid mass.
Big simple cyst, no big deal. Next case.

Wrong!  This is a large grade 3 triple negative invasive ductal carcinoma.  

The problem here is inappropriate gain.  The ultrasound is only as good as the operator. With the twist of a few knobs, you can make any solid mass appear cystic.  DON'T DO THIS!

Ensure that the gain is appropriate on all exams.  A good way to gauge is to ensure that the background fat is isoechoic (gray) and not anechoic (black) as in this case. 
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A lesion is present underneath the nipple, however poor technique limits even the most basic assessment as to if it is cystic or solid.
Diagnosis please??

If you hesitated, I don't blame you. How in the world can you tell what this is?  You can't, the images are non-diagnostic.

Clearly, there is some sort of mass or cyst underneath the nipple.  But one is not able to say much more than that about it.  And what happened to the pec muscle.  

There are several special techniques that can be used when imaging near the nipple-areolar complex that would have fixed this image.

The frightening and discouraging thing is what the report stated on this case. "Lesion in the subareolar left breast. MRI is recommended to evaluate."  Poor technique and lazy interpretation made this a wasted exam.
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Two ultrasound images of the same mass performed 2 days apart. Notice the dramatic difference in image quality.
Using the right equipment and appropriate technique is essential when performing breast ultrasound.  Look at the difference in image quality and how the image on the right clearly shows a complex cyst. The next step is then automatic, a biopsy is required. 

​However, if given only the first low quality image on the left, it becomes much more difficult to make a definitive diagnosis and actionable next step.

Don't overlook the importance of high-quality ultrasound

Take the time to learn appropriate ultrasound imaging technique and then practice.  Becoming skilled at performing the exam will pay huge dividends when trying to interpret an exam that a sonographer or someone else may have obtained. There are many special techniques and things to look for on a breast ultrasound that can make your life so much easier.

If you want to learn more about all aspects of breast imaging, including extensive coverage of breast ultrasound, then check out our signature Master Breast Imaging training program. You will not find a more comprehensive, practical way to learn. 

Also, stay tuned because you will receive part 3 of our free Breast Imaging Starter Kit in your email inbox in the next few days.  This covers an approach to interpreting breast MRI.  The corresponding practice cases are found below.

Part III - Breast MRI

By now you should have gone through part III of the Breast Imaging Starter Kit.  If you still need a copy, click here .  

In part III, we covered a systematic approach to interpreting a breast MRI exam.  Again, just like with mammography, feel free to tailor the approach to your liking.  Your facility may perform slightly different or fewer sequences. This is ok, don't panic. Simply use our approach as a launching pad and adjust as needed.  The most important thing is to simply have an approach and repeat it every single time.  

Below are a few practice cases to help illustrate the importance of a systematic approach.

MRI Case 1
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MRI Case 1 - Incidental Left Lung Mass

Even though the exam is designed to image the breasts, a large part of the neck base, chest and upper abdomen are often included in the images.

You are responsible for any major findings. The patient in case 1 had an incidentally detected solitary fibrous tumor of the pleura which was subsequently excised. 

Typically, the most useful sequences to evaluate the "non-breast" structures tend to be the STIR and any non-fat saturated T1 images.  

MRI Case 2
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MRI Case 2 - Motion Artifact

Ok, so this was a pretty easy case. But it is a very important case, because it is very common.  A MRI exam is not a very comfortable exam, so patients frequently move or shift around and this causes all kinds of problems when you are doing sequential imaging and trying to assess kinetics. The best way to assess for motion is to pick a specific slice and then quickly go back and forth between the pre- and post-contrast sequences. If there is patient motion it will look like the patient is dancing or wiggling as shown in the images above.  You may also get "washout" kinetics along the edges of the tissues.

MRI Case 3

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MRI Case 3 - Malignancy on Several Sequences

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Suspicious enhancing mass in the lower outer quadrant of the left breast.
Remember, each sequence on a MRI exam has a unique purpose.  Don't just blindly scroll through every sequence.  

The MIP is to get an overview, on post-contrast images you are looking for enhancement, on the STIR images for T2 hyperintense lesions in the breast or elsewhere in the body.

Once you find a mass, determine whether it enhances. If so, what is the kinetic profile?  Is it T2 bright? Does it contain fat on the non-fat saturated T1 sequence?  You are a detective, use each breast MRI sequence as a tool to help solve the mystery.

MRI Case 4

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MRI Case 4 - Multifocal Malignancy

When evaluating a newly diagnosed cancer patient for extent of disease, there are a few things you want to evaluate.
  • Size / Extent of the lesion
  • Multifocal or multicentric disease
  • Contralateral malignancy
  • Involvement of the skin, nipple or chest wall
  • Lymph nodes (axillary & internal mammary)
  • Any distant metastases (rib lesions, liver mets, lung nodules, etc)

Wrap-Up

MRI is the most sensitive, best way to image the breasts. However it is also the most complicated and sometimes difficult to interpret.  Ensuring excellent technique, being able to troubleshoot, using a systematic approach and knowing a few specific workups will allow you to provide a real service to your patients and referring providers.

If you want to learn more about all aspects of breast imaging, including extensive coverage of breast MRI, then check out our signature Master Breast Imaging training program. You will not find a more comprehensive, practical way to learn. ​
Learn More About Our Master Breast Imaging Training

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