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Breast Imaging: From 1965 to the Present¹

¹ From the Department of Radiology, University of California Medical Center, 2330 Post St, Room 180, San Francisco, CA 94115. Received August 31, 1999; revision requested October 12; revision received November 4; accepted November 12. Address reprint requests to the author.

View larger version (63K): [in a new window]   Figure 1a. Standard negative mammograms: 1965-1975. Standard examination included a 90° lateral and craniocaudal (CC) view of each breast. (a) Lateral and (b) CC direct-exposure film mammograms. There was only slight (if any) compression of the breast during exposure, which impaired depiction of tissues close to the chest wall because the x-ray beam could not effectively penetrate these thicker regions of the breast without grossly overexposing the thinner regions close to the nipple. (c) Lateral and (d) CC xeromammograms. The wide latitude of the xeroradiographic imaging process overcame the previously described limitation of direct-exposure film mammography. However, the perceived need to include chest wall structures in the image field on the 90° lateral view compromised the detail of these images, because this required placement of a sponge between the breast and imaging cassette to permit use of gentle compression. (e) Lateral and (f) CC screen-film mammograms. This imaging technique was coupled with the use of a dedicated molybdenum-anode x-ray unit that provided uniform-thickness breast compression so that both thick and thin regions of the breast were properly exposed in the image. However, the combination of uniform-thickness breast compression and the use of the 90° lateral projection limited the amount of posterior tissues included in the image field.

View larger version (44K): [in a new window]   Figure 1b. Standard negative mammograms: 1965-1975. Standard examination included a 90° lateral and craniocaudal (CC) view of each breast. (a) Lateral and (b) CC direct-exposure film mammograms. There was only slight (if any) compression of the breast during exposure, which impaired depiction of tissues close to the chest wall because the x-ray beam could not effectively penetrate these thicker regions of the breast without grossly overexposing the thinner regions close to the nipple. (c) Lateral and (d) CC xeromammograms. The wide latitude of the xeroradiographic imaging process overcame the previously described limitation of direct-exposure film mammography. However, the perceived need to include chest wall structures in the image field on the 90° lateral view compromised the detail of these images, because this required placement of a sponge between the breast and imaging cassette to permit use of gentle compression. (e) Lateral and (f) CC screen-film mammograms. This imaging technique was coupled with the use of a dedicated molybdenum-anode x-ray unit that provided uniform-thickness breast compression so that both thick and thin regions of the breast were properly exposed in the image. However, the combination of uniform-thickness breast compression and the use of the 90° lateral projection limited the amount of posterior tissues included in the image field.

View larger version (97K): [in a new window]   Figure 1c. Standard negative mammograms: 1965-1975. Standard examination included a 90° lateral and craniocaudal (CC) view of each breast. (a) Lateral and (b) CC direct-exposure film mammograms. There was only slight (if any) compression of the breast during exposure, which impaired depiction of tissues close to the chest wall because the x-ray beam could not effectively penetrate these thicker regions of the breast without grossly overexposing the thinner regions close to the nipple. (c) Lateral and (d) CC xeromammograms. The wide latitude of the xeroradiographic imaging process overcame the previously described limitation of direct-exposure film mammography. However, the perceived need to include chest wall structures in the image field on the 90° lateral view compromised the detail of these images, because this required placement of a sponge between the breast and imaging cassette to permit use of gentle compression. (e) Lateral and (f) CC screen-film mammograms. This imaging technique was coupled with the use of a dedicated molybdenum-anode x-ray unit that provided uniform-thickness breast compression so that both thick and thin regions of the breast were properly exposed in the image. However, the combination of uniform-thickness breast compression and the use of the 90° lateral projection limited the amount of posterior tissues included in the image field.

View larger version (86K): [in a new window]   Figure 1d. Standard negative mammograms: 1965-1975. Standard examination included a 90° lateral and craniocaudal (CC) view of each breast. (a) Lateral and (b) CC direct-exposure film mammograms. There was only slight (if any) compression of the breast during exposure, which impaired depiction of tissues close to the chest wall because the x-ray beam could not effectively penetrate these thicker regions of the breast without grossly overexposing the thinner regions close to the nipple. (c) Lateral and (d) CC xeromammograms. The wide latitude of the xeroradiographic imaging process overcame the previously described limitation of direct-exposure film mammography. However, the perceived need to include chest wall structures in the image field on the 90° lateral view compromised the detail of these images, because this required placement of a sponge between the breast and imaging cassette to permit use of gentle compression. (e) Lateral and (f) CC screen-film mammograms. This imaging technique was coupled with the use of a dedicated molybdenum-anode x-ray unit that provided uniform-thickness breast compression so that both thick and thin regions of the breast were properly exposed in the image. However, the combination of uniform-thickness breast compression and the use of the 90° lateral projection limited the amount of posterior tissues included in the image field.

View larger version (65K): [in a new window]   Figure 1e. Standard negative mammograms: 1965-1975. Standard examination included a 90° lateral and craniocaudal (CC) view of each breast. (a) Lateral and (b) CC direct-exposure film mammograms. There was only slight (if any) compression of the breast during exposure, which impaired depiction of tissues close to the chest wall because the x-ray beam could not effectively penetrate these thicker regions of the breast without grossly overexposing the thinner regions close to the nipple. (c) Lateral and (d) CC xeromammograms. The wide latitude of the xeroradiographic imaging process overcame the previously described limitation of direct-exposure film mammography. However, the perceived need to include chest wall structures in the image field on the 90° lateral view compromised the detail of these images, because this required placement of a sponge between the breast and imaging cassette to permit use of gentle compression. (e) Lateral and (f) CC screen-film mammograms. This imaging technique was coupled with the use of a dedicated molybdenum-anode x-ray unit that provided uniform-thickness breast compression so that both thick and thin regions of the breast were properly exposed in the image. However, the combination of uniform-thickness breast compression and the use of the 90° lateral projection limited the amount of posterior tissues included in the image field.

View larger version (59K): [in a new window]   Figure 1f. Standard negative mammograms: 1965-1975. Standard examination included a 90° lateral and craniocaudal (CC) view of each breast. (a) Lateral and (b) CC direct-exposure film mammograms. There was only slight (if any) compression of the breast during exposure, which impaired depiction of tissues close to the chest wall because the x-ray beam could not effectively penetrate these thicker regions of the breast without grossly overexposing the thinner regions close to the nipple. (c) Lateral and (d) CC xeromammograms. The wide latitude of the xeroradiographic imaging process overcame the previously described limitation of direct-exposure film mammography. However, the perceived need to include chest wall structures in the image field on the 90° lateral view compromised the detail of these images, because this required placement of a sponge between the breast and imaging cassette to permit use of gentle compression. (e) Lateral and (f) CC screen-film mammograms. This imaging technique was coupled with the use of a dedicated molybdenum-anode x-ray unit that provided uniform-thickness breast compression so that both thick and thin regions of the breast were properly exposed in the image. However, the combination of uniform-thickness breast compression and the use of the 90° lateral projection limited the amount of posterior tissues included in the image field.

View larger version (81K): [in a new window]   Figure 2a. Standard negative mammograms: current. Standard examination now involves (a) MLO and (b) CC views of the breasts because the oblique view includes more posterior tissues in the image field than does the 90° lateral view. Also note that most breast structures are depicted more effectively than in the 1965-1975 period because of improvements in mammographic equipment, film, screens, film processing, grids, breast compression, and positioning.

View larger version (74K): [in a new window]   Figure 2b. Standard negative mammograms: current. Standard examination now involves (a) MLO and (b) CC views of the breasts because the oblique view includes more posterior tissues in the image field than does the 90° lateral view. Also note that most breast structures are depicted more effectively than in the 1965-1975 period because of improvements in mammographic equipment, film, screens, film processing, grids, breast compression, and positioning.

View larger version (70K): [in a new window]   Figure 3a. Standard negative mammograms: 1975 and current. Images of the same breast over a 25-year period. (a) A 90° lateral screen-film mammogram from 1975. (b) Current MLO screen-film mammogram. (c) CC screen-film mammogram from 1975. (d) Current CC screen-film mammogram. Note that the current images not only display much greater contrast and sharpness, but they also include in the image field several centimeters of additional breast tissue close to the chest wall. This latter comparison is facilitated by noting the amount of parenchyma included in the image field that is posterior to the (stable) island of benign fibroglandular tissue (arrow) in the upper medial portion of the breast (take into account that a and c are displayed relatively larger in size than b and d).

View larger version (104K): [in a new window]   Figure 3b. Standard negative mammograms: 1975 and current. Images of the same breast over a 25-year period. (a) A 90° lateral screen-film mammogram from 1975. (b) Current MLO screen-film mammogram. (c) CC screen-film mammogram from 1975. (d) Current CC screen-film mammogram. Note that the current images not only display much greater contrast and sharpness, but they also include in the image field several centimeters of additional breast tissue close to the chest wall. This latter comparison is facilitated by noting the amount of parenchyma included in the image field that is posterior to the (stable) island of benign fibroglandular tissue (arrow) in the upper medial portion of the breast (take into account that a and c are displayed relatively larger in size than b and d).

View larger version (61K): [in a new window]   Figure 3c. Standard negative mammograms: 1975 and current. Images of the same breast over a 25-year period. (a) A 90° lateral screen-film mammogram from 1975. (b) Current MLO screen-film mammogram. (c) CC screen-film mammogram from 1975. (d) Current CC screen-film mammogram. Note that the current images not only display much greater contrast and sharpness, but they also include in the image field several centimeters of additional breast tissue close to the chest wall. This latter comparison is facilitated by noting the amount of parenchyma included in the image field that is posterior to the (stable) island of benign fibroglandular tissue (arrow) in the upper medial portion of the breast (take into account that a and c are displayed relatively larger in size than b and d).

View larger version (97K): [in a new window]   Figure 3d. Standard negative mammograms: 1975 and current. Images of the same breast over a 25-year period. (a) A 90° lateral screen-film mammogram from 1975. (b) Current MLO screen-film mammogram. (c) CC screen-film mammogram from 1975. (d) Current CC screen-film mammogram. Note that the current images not only display much greater contrast and sharpness, but they also include in the image field several centimeters of additional breast tissue close to the chest wall. This latter comparison is facilitated by noting the amount of parenchyma included in the image field that is posterior to the (stable) island of benign fibroglandular tissue (arrow) in the upper medial portion of the breast (take into account that a and c are displayed relatively larger in size than b and d).

View larger version (212K): [in a new window]   Figure 4a. Circumscribed noncalcified mass: 1965-1975. Most such lesions were large and palpable, and therefore patients underwent excisional biopsy. (a) CC xeromammogram shows a 3-cm round circumscribed mass (arrow), which was excised and found to be a simple cyst. (b) A 90° lateral direct-exposure film mammogram in a different patient shows a 2.5-cm oval circumscribed mass (arrow), which was excised and found to be a fibroadenoma.

View larger version (161K): [in a new window]   Figure 4b. Circumscribed noncalcified mass: 1965-1975. Most such lesions were large and palpable, and therefore patients underwent excisional biopsy. (a) CC xeromammogram shows a 3-cm round circumscribed mass (arrow), which was excised and found to be a simple cyst. (b) A 90° lateral direct-exposure film mammogram in a different patient shows a 2.5-cm oval circumscribed mass (arrow), which was excised and found to be a fibroadenoma.

View larger version (116K): [in a new window]   Figure 5a. Circumscribed noncalcified mass: 1965-1975. (a) CC screen-film mammogram demonstrates a nonpalpable mass (arrow). During the course of needle localization prior to planned excision of this mass, clear fluid was seen to come from the hub of the localizing needle, which was suggestive of fortuitous puncture of a cyst. Additional fluid was then aspirated, air was injected in its place, and mammography was repeated. (b) CC screen-film pneumocystogram demonstrates an air-filled cavity (with no mural irregularity) instead of the mass. This established the diagnosis of a simple cyst, which obviated excisional biopsy.

View larger version (110K): [in a new window]   Figure 5b. Circumscribed noncalcified mass: 1965-1975. (a) CC screen-film mammogram demonstrates a nonpalpable mass (arrow). During the course of needle localization prior to planned excision of this mass, clear fluid was seen to come from the hub of the localizing needle, which was suggestive of fortuitous puncture of a cyst. Additional fluid was then aspirated, air was injected in its place, and mammography was repeated. (b) CC screen-film pneumocystogram demonstrates an air-filled cavity (with no mural irregularity) instead of the mass. This established the diagnosis of a simple cyst, which obviated excisional biopsy.

View larger version (127K): [in a new window]   Figure 6a. Circumscribed noncalcified mass: current. Most such lesions now are detected at mammographic screening, are nonpalpable even in retrospect, and are next evaluated with US to establish or exclude the diagnosis of a simple cyst. (a) CC screen-film mammogram demonstrates a 6 x 8-mm circumscribed mass (arrow). (b) Transverse sonogram shows the mass (arrow) to be anechoic and to exhibit smooth margins, a well-defined posterior border, and increased sound transmission. These sonographic features permit the reliable diagnosis of a simple cyst, a benign lesion that requires no further work-up.

View larger version (145K): [in a new window]   Figure 6b. Circumscribed noncalcified mass: current. Most such lesions now are detected at mammographic screening, are nonpalpable even in retrospect, and are next evaluated with US to establish or exclude the diagnosis of a simple cyst. (a) CC screen-film mammogram demonstrates a 6 x 8-mm circumscribed mass (arrow). (b) Transverse sonogram shows the mass (arrow) to be anechoic and to exhibit smooth margins, a well-defined posterior border, and increased sound transmission. These sonographic features permit the reliable diagnosis of a simple cyst, a benign lesion that requires no further work-up.

View larger version (152K): [in a new window]   Figure 7a. Circumscribed noncalcified mass: current. (a) CC screen-film spot-compression magnification mammogram demonstrates a 10 x 12-mm circumscribed mass (arrow), which was nonpalpable. (b) Transverse sonogram shows that the mass (cursors, arrow) is hypoechoic with homogeneous low-amplitude internal echoes, is wider than tall, and has smooth margins with a thin echogenic rim. This combination of mammographic and sonographic features indicates that the mass is solid, rather than cystic, and that it is probably benign (likelihood of malignancy, <2%). Most such lesions now are managed with periodic mammographic surveillance, rather than with any form of tissue diagnosis; the illustrated lesion was stable over a 3-year period of surveillance.

View larger version (154K): [in a new window]   Figure 7b. Circumscribed noncalcified mass: current. (a) CC screen-film spot-compression magnification mammogram demonstrates a 10 x 12-mm circumscribed mass (arrow), which was nonpalpable. (b) Transverse sonogram shows that the mass (cursors, arrow) is hypoechoic with homogeneous low-amplitude internal echoes, is wider than tall, and has smooth margins with a thin echogenic rim. This combination of mammographic and sonographic features indicates that the mass is solid, rather than cystic, and that it is probably benign (likelihood of malignancy, <2%). Most such lesions now are managed with periodic mammographic surveillance, rather than with any form of tissue diagnosis; the illustrated lesion was stable over a 3-year period of surveillance.

View larger version (104K): [in a new window]   Figure 8. Grouped microcalcifications: 1965-1975. CC direct-exposure film mammogram demonstrates grouped microcalcifications (curved arrow) within a large irregular mass (straight arrows). The calcifications are seen only faintly, primarily because of the low contrast inherent in direct-exposure film mammography. Findings from biopsy showed invasive ductal carcinoma with areas of ductal carcinoma in situ (DCIS).

View larger version (159K): [in a new window]   Figure 9. Grouped microcalcifications: 1965-1975. CC xeromammogram demonstrates a small cluster of microcalcifications (arrow), which was suggestive of malignancy. Findings from biopsy showed DCIS.

View larger version (181K): [in a new window]   Figure 10. Grouped microcalcifications: 1965-1975. A 90° lateral xeromammogram shows a large irregular mass (straight arrows) close to the chest wall; mass is associated with numerous microcalcifications. Also note a separate 6 x 9-mm cluster of microcalcifications (curved arrow) close to the nipple. Findings from biopsy showed invasive ductal carcinoma with multifocal DCIS.

View larger version (149K): [in a new window]   Figure 11a. Grouped microcalcifications: current. (a) CC screen-film mammogram shows a 3 x 4-mm cluster of microcalcifications (arrow). (b) CC screen-film spot-compression magnification mammogram displays the pleomorphic shapes of the calcific particles (straight arrow) more effectively but also demonstrates a second group of microcalcifications several centimeters distant (curved arrow). Findings from biopsy showed multifocal DCIS, which was subsequently treated with mastectomy rather than breast preservation.

View larger version (139K): [in a new window]   Figure 11b. Grouped microcalcifications: current. (a) CC screen-film mammogram shows a 3 x 4-mm cluster of microcalcifications (arrow). (b) CC screen-film spot-compression magnification mammogram displays the pleomorphic shapes of the calcific particles (straight arrow) more effectively but also demonstrates a second group of microcalcifications several centimeters distant (curved arrow). Findings from biopsy showed multifocal DCIS, which was subsequently treated with mastectomy rather than breast preservation.

View larger version (132K): [in a new window]   Figure 12a. Typical breast cancer—mass: 1965-1975. Most such lesions were large and palpable. Many were locally advanced tumors. (a) CC direct-exposure mammogram shows a 3-cm spiculated mass (straight arrow), associated with nipple retraction (curved arrow). Findings from biopsy showed invasive ductal carcinoma extending centrally to involve the nipple. (b) CC direct-exposure mammogram shows a poorly defined area of increased opacity (straight arrows), associated with generalized skin thickening (curved arrows). Findings from biopsy showed invasive ductal carcinoma with tumor extending to the skin and subdermal lymphatic vessels. (c) A 90° lateral xeromammogram shows a subtle 4-cm spiculated mass (straight arrows), associated with generalized skin thickening (curved arrows). Findings from biopsy showed invasive ductal carcinoma (inflammatory carcinoma).

View larger version (66K): [in a new window]   Figure 12b. Typical breast cancer—mass: 1965-1975. Most such lesions were large and palpable. Many were locally advanced tumors. (a) CC direct-exposure mammogram shows a 3-cm spiculated mass (straight arrow), associated with nipple retraction (curved arrow). Findings from biopsy showed invasive ductal carcinoma extending centrally to involve the nipple. (b) CC direct-exposure mammogram shows a poorly defined area of increased opacity (straight arrows), associated with generalized skin thickening (curved arrows). Findings from biopsy showed invasive ductal carcinoma with tumor extending to the skin and subdermal lymphatic vessels. (c) A 90° lateral xeromammogram shows a subtle 4-cm spiculated mass (straight arrows), associated with generalized skin thickening (curved arrows). Findings from biopsy showed invasive ductal carcinoma (inflammatory carcinoma).

View larger version (112K): [in a new window]   Figure 12c. Typical breast cancer—mass: 1965-1975. Most such lesions were large and palpable. Many were locally advanced tumors. (a) CC direct-exposure mammogram shows a 3-cm spiculated mass (straight arrow), associated with nipple retraction (curved arrow). Findings from biopsy showed invasive ductal carcinoma extending centrally to involve the nipple. (b) CC direct-exposure mammogram shows a poorly defined area of increased opacity (straight arrows), associated with generalized skin thickening (curved arrows). Findings from biopsy showed invasive ductal carcinoma with tumor extending to the skin and subdermal lymphatic vessels. (c) A 90° lateral xeromammogram shows a subtle 4-cm spiculated mass (straight arrows), associated with generalized skin thickening (curved arrows). Findings from biopsy showed invasive ductal carcinoma (inflammatory carcinoma).

View larger version (99K): [in a new window]   Figure 13a. Typical breast cancer—mass: 1965-1975. (a) CC direct-exposure film mammogram shows a 7-mm spiculated mass (arrow), which was subtle in manifestation. Findings from biopsy showed invasive ductal carcinoma. (b) CC direct-exposure film mammogram shows a 1-cm mass (arrow) with indistinct margins, which was subtle in manifestation. Findings from biopsy showed invasive ductal carcinoma.

View larger version (84K): [in a new window]   Figure 13b. Typical breast cancer—mass: 1965-1975. (a) CC direct-exposure film mammogram shows a 7-mm spiculated mass (arrow), which was subtle in manifestation. Findings from biopsy showed invasive ductal carcinoma. (b) CC direct-exposure film mammogram shows a 1-cm mass (arrow) with indistinct margins, which was subtle in manifestation. Findings from biopsy showed invasive ductal carcinoma.

View larger version (116K): [in a new window]   Figure 14a. Typical breast cancer—mass: current. The superior image quality of current mammography facilitates the detection of small nonpalpable breast cancers (compare with Fig 13). (a) MLO screen-film mammogram and (b) 90° lateral screen-film spot-compression magnification mammogram demonstrate a 6 x 9-mm spiculated mass (arrow). Both the mass and its spiculations are depicted more clearly in b. Findings from biopsy showed invasive ductal carcinoma. (c) MLO and (d) CC screen-film mammograms show a 7 x 9-mm mass (arrow) with indistinct margins in the lower outer quadrant, close to the chest wall. Findings from biopsy showed invasive ductal carcinoma.

View larger version (128K): [in a new window]   Figure 14b. Typical breast cancer—mass: current. The superior image quality of current mammography facilitates the detection of small nonpalpable breast cancers (compare with Fig 13). (a) MLO screen-film mammogram and (b) 90° lateral screen-film spot-compression magnification mammogram demonstrate a 6 x 9-mm spiculated mass (arrow). Both the mass and its spiculations are depicted more clearly in b. Findings from biopsy showed invasive ductal carcinoma. (c) MLO and (d) CC screen-film mammograms show a 7 x 9-mm mass (arrow) with indistinct margins in the lower outer quadrant, close to the chest wall. Findings from biopsy showed invasive ductal carcinoma.

View larger version (129K): [in a new window]   Figure 14c. Typical breast cancer—mass: current. The superior image quality of current mammography facilitates the detection of small nonpalpable breast cancers (compare with Fig 13). (a) MLO screen-film mammogram and (b) 90° lateral screen-film spot-compression magnification mammogram demonstrate a 6 x 9-mm spiculated mass (arrow). Both the mass and its spiculations are depicted more clearly in b. Findings from biopsy showed invasive ductal carcinoma. (c) MLO and (d) CC screen-film mammograms show a 7 x 9-mm mass (arrow) with indistinct margins in the lower outer quadrant, close to the chest wall. Findings from biopsy showed invasive ductal carcinoma.

View larger version (120K): [in a new window]   Figure 14d. Typical breast cancer—mass: current. The superior image quality of current mammography facilitates the detection of small nonpalpable breast cancers (compare with Fig 13). (a) MLO screen-film mammogram and (b) 90° lateral screen-film spot-compression magnification mammogram demonstrate a 6 x 9-mm spiculated mass (arrow). Both the mass and its spiculations are depicted more clearly in b. Findings from biopsy showed invasive ductal carcinoma. (c) MLO and (d) CC screen-film mammograms show a 7 x 9-mm mass (arrow) with indistinct margins in the lower outer quadrant, close to the chest wall. Findings from biopsy showed invasive ductal carcinoma.

View larger version (185K): [in a new window]   Figure 15. Typical breast cancer—calcifications: 1965-1975. Those cancers detected at mammography as grouped microcalcifications often were large lesions. CC xeromammogram shows extensive grouped microcalcifications (arrows) occupying a large area in the middle and posterior thirds of the breast. Findings from biopsy showed a 2.5-cm invasive ductal carcinoma (not depicted at mammography), with extensive associated DCIS.

View larger version (141K): [in a new window]   Figure 16a. Typical breast cancer—calcifications: current. (a) CC screen-film mammogram and (b) CC screen-film spot-compression magnification mammogram show a 5 x 9-mm area of subtle microcalcifications (arrows), adjacent to one coarse calcification. Pleomorphic microcalcifications are seen more clearly in b. Findings from biopsy showed DCIS. (c) CC screen-film mammogram shows subtle, possibly linearly distributed microcalcifications (arrow), which prompted further work-up with (d) CC screen-film spot-compression magnification mammogram, which demonstrates that the microcalcifications (arrows) are much more extensive, include some linear-shaped calcific particles, and occupy a segmental distribution. Findings from biopsy showed multifocal DCIS.

View larger version (142K): [in a new window]   Figure 16b. Typical breast cancer—calcifications: current. (a) CC screen-film mammogram and (b) CC screen-film spot-compression magnification mammogram show a 5 x 9-mm area of subtle microcalcifications (arrows), adjacent to one coarse calcification. Pleomorphic microcalcifications are seen more clearly in b. Findings from biopsy showed DCIS. (c) CC screen-film mammogram shows subtle, possibly linearly distributed microcalcifications (arrow), which prompted further work-up with (d) CC screen-film spot-compression magnification mammogram, which demonstrates that the microcalcifications (arrows) are much more extensive, include some linear-shaped calcific particles, and occupy a segmental distribution. Findings from biopsy showed multifocal DCIS.

View larger version (116K): [in a new window]   Figure 16c. Typical breast cancer—calcifications: current. (a) CC screen-film mammogram and (b) CC screen-film spot-compression magnification mammogram show a 5 x 9-mm area of subtle microcalcifications (arrows), adjacent to one coarse calcification. Pleomorphic microcalcifications are seen more clearly in b. Findings from biopsy showed DCIS. (c) CC screen-film mammogram shows subtle, possibly linearly distributed microcalcifications (arrow), which prompted further work-up with (d) CC screen-film spot-compression magnification mammogram, which demonstrates that the microcalcifications (arrows) are much more extensive, include some linear-shaped calcific particles, and occupy a segmental distribution. Findings from biopsy showed multifocal DCIS.

View larger version (132K): [in a new window]   Figure 16d. Typical breast cancer—calcifications: current. (a) CC screen-film mammogram and (b) CC screen-film spot-compression magnification mammogram show a 5 x 9-mm area of subtle microcalcifications (arrows), adjacent to one coarse calcification. Pleomorphic microcalcifications are seen more clearly in b. Findings from biopsy showed DCIS. (c) CC screen-film mammogram shows subtle, possibly linearly distributed microcalcifications (arrow), which prompted further work-up with (d) CC screen-film spot-compression magnification mammogram, which demonstrates that the microcalcifications (arrows) are much more extensive, include some linear-shaped calcific particles, and occupy a segmental distribution. Findings from biopsy showed multifocal DCIS.

View larger version (37K): [in a new window]   Figure 17. Breast implants: 1965-1975. A 90° lateral direct-exposure film mammogram shows a breast augmented with a prepectoral silicone-filled implant. Note that little breast parenchyma is depicted and that only the anterior portion of the implant (arrows) is included in the image field.

View larger version (122K): [in a new window]   Figure 18. Breast implants: 1965-1975. A 90° lateral xeromammogram demonstrates a prepectoral silicone-filled implant. The wide latitude of xeroradiography permits effective simultaneous depiction of all imaged structures, from chest wall to implant to native fibroglandular tissue to breast fat. There is extracapsular rupture of the implant, which is shown by the demonstration of numerous silicone nodules (arrows) superimposed over the implant, indicating the presence of free silicone within the breast parenchyma.

View larger version (60K): [in a new window]   Figure 19a. Breast implants: current. MLO screen-film mammograms of a breast augmented with a prepectoral silicone-filled implant, with (a) implant included in the image field and (b) implant displaced posteriorly, which more effectively portrays the native fibroglandular tissue. Just anterior to the implant, there is an area of architectural distortion (arrow), which is seen only in b. This finding prompted further imaging with (c) implant-displaced spot-compression magnification mammogram, obtained with the x-ray beam aligned tangential to the area of architectural distortion, showing a 1.5-cm spiculated mass containing microcalcifications (arrow). Findings from biopsy showed invasive ductal carcinoma with a minor component of DCIS.

View larger version (85K): [in a new window]   Figure 19b. Breast implants: current. MLO screen-film mammograms of a breast augmented with a prepectoral silicone-filled implant, with (a) implant included in the image field and (b) implant displaced posteriorly, which more effectively portrays the native fibroglandular tissue. Just anterior to the implant, there is an area of architectural distortion (arrow), which is seen only in b. This finding prompted further imaging with (c) implant-displaced spot-compression magnification mammogram, obtained with the x-ray beam aligned tangential to the area of architectural distortion, showing a 1.5-cm spiculated mass containing microcalcifications (arrow). Findings from biopsy showed invasive ductal carcinoma with a minor component of DCIS.

View larger version (94K): [in a new window]   Figure 19c. Breast implants: current. MLO screen-film mammograms of a breast augmented with a prepectoral silicone-filled implant, with (a) implant included in the image field and (b) implant displaced posteriorly, which more effectively portrays the native fibroglandular tissue. Just anterior to the implant, there is an area of architectural distortion (arrow), which is seen only in b. This finding prompted further imaging with (c) implant-displaced spot-compression magnification mammogram, obtained with the x-ray beam aligned tangential to the area of architectural distortion, showing a 1.5-cm spiculated mass containing microcalcifications (arrow). Findings from biopsy showed invasive ductal carcinoma with a minor component of DCIS.

View larger version (82K): [in a new window]   Figure 20a. Breast implants: current. MR imaging, because of its ability to produce cross-sectional images and to depict silicone at substantially different signal intensity than all other structures, depicts the integrity of breast implants with a high degree of accuracy. (a) Sagittal T2-weighted fast spin-echo MR image with water suppression (4,000/200 [repetition time msec/echo time msec]) shows a breast augmented with a prepectoral silicone-filled implant and demonstrates free silicone (arrow) immediately posterior to the implant shell. This finding represented the only imaging evidence of extracapsular implant rupture in this case, insofar as neither mammography nor US was able to depict any abnormality. (b) Transverse T2-weighted fast spin-echo MR image with water suppression (4,000/200) shows a breast augmented with a prepectoral silicone-filled implant and demonstrates that the silicone is contained within the implant capsule, with collapse of the implant shell (linguine sign [arrows]). MR imaging is the most sensitive breast imaging examination to indicate the presence of intracapsular implant rupture. (Image courtesy of Dulcy E. Wolverton, MD, Department of Radiology, University of California Medical Center, San Francisco, Calif.)

View larger version (86K): [in a new window]   Figure 20b. Breast implants: current. MR imaging, because of its ability to produce cross-sectional images and to depict silicone at substantially different signal intensity than all other structures, depicts the integrity of breast implants with a high degree of accuracy. (a) Sagittal T2-weighted fast spin-echo MR image with water suppression (4,000/200 [repetition time msec/echo time msec]) shows a breast augmented with a prepectoral silicone-filled implant and demonstrates free silicone (arrow) immediately posterior to the implant shell. This finding represented the only imaging evidence of extracapsular implant rupture in this case, insofar as neither mammography nor US was able to depict any abnormality. (b) Transverse T2-weighted fast spin-echo MR image with water suppression (4,000/200) shows a breast augmented with a prepectoral silicone-filled implant and demonstrates that the silicone is contained within the implant capsule, with collapse of the implant shell (linguine sign [arrows]). MR imaging is the most sensitive breast imaging examination to indicate the presence of intracapsular implant rupture. (Image courtesy of Dulcy E. Wolverton, MD, Department of Radiology, University of California Medical Center, San Francisco, Calif.)

View larger version (115K): [in a new window]   Figure 21a. Imaging-guided tissue diagnosis: 1965-1975. Freehand needle localization was the most accurate method available. The needle, which was taped to the skin to maximize stability, served as a palpable guide for the surgeon during excisional biopsy. (a) These 90° lateral and (b) CC screen-film mammograms document placement of a 9-cm spinal needle through a large mass (arrow). Findings from biopsy showed fibroadenoma.

View larger version (109K): [in a new window]   Figure 21b. Imaging-guided tissue diagnosis: 1965-1975. Freehand needle localization was the most accurate method available. The needle, which was taped to the skin to maximize stability, served as a palpable guide for the surgeon during excisional biopsy. (a) These 90° lateral and (b) CC screen-film mammograms document placement of a 9-cm spinal needle through a large mass (arrow). Findings from biopsy showed fibroadenoma.

View larger version (71K): [in a new window]   Figure 22a. Imaging-guided tissue diagnosis: 1965-1975. (a) CC screen-film mammogram demonstrates a needle placed close to a cluster of microcalcifications (arrow). (b) Screen-film radiograph of the excised biopsy specimen documents removal of the targeted calcifications (arrow), which are in the middle of the specimen. Uncertainty about the stability of the localizing needle during the time between mammographic imaging and lesion excision caused many surgeons to remove large amounts of tissue even when needle placement was accurate. Findings from biopsy showed sclerosing adenosis.

View larger version (82K): [in a new window]   Figure 22b. Imaging-guided tissue diagnosis: 1965-1975. (a) CC screen-film mammogram demonstrates a needle placed close to a cluster of microcalcifications (arrow). (b) Screen-film radiograph of the excised biopsy specimen documents removal of the targeted calcifications (arrow), which are in the middle of the specimen. Uncertainty about the stability of the localizing needle during the time between mammographic imaging and lesion excision caused many surgeons to remove large amounts of tissue even when needle placement was accurate. Findings from biopsy showed sclerosing adenosis.

View larger version (111K): [in a new window]   Figure 23a. Imaging-guided tissue diagnosis: current. US-guided percutaneous biopsy is practical for any lesion that is depicted at US. (a) A 90° lateral screen-film mammogram shows a 6 x 8-mm noncalcified mass (arrow) with indistinct margins, which was nonpalpable even in retrospect. (b) Transverse sonogram shows the mass (arrow) to be oval and wider than tall, with minimally irregular margins, which confirms the mammographic suggestion of malignancy. (c) Transverse sonogram shows a biopsy needle (arrow) placed within the mass. This procedure, which was performed with real-time US guidance, was completed in less than 5 minutes. (d) Repeat 90° lateral screen-film mammogram, which was obtained immediately after tissue sampling (in this case, fine-needle aspiration biopsy), shows that the mass is partially obscured by a small hematoma (arrow), with the suggestion of a small air-filled cavity at the aspiration site. Cytologic examination revealed malignant cells, which were suggestive of invasive lobular carcinoma. Histologic examination (subsequent breast-preservation surgery) showed invasive lobular carcinoma.

View larger version (140K): [in a new window]   Figure 23b. Imaging-guided tissue diagnosis: current. US-guided percutaneous biopsy is practical for any lesion that is depicted at US. (a) A 90° lateral screen-film mammogram shows a 6 x 8-mm noncalcified mass (arrow) with indistinct margins, which was nonpalpable even in retrospect. (b) Transverse sonogram shows the mass (arrow) to be oval and wider than tall, with minimally irregular margins, which confirms the mammographic suggestion of malignancy. (c) Transverse sonogram shows a biopsy needle (arrow) placed within the mass. This procedure, which was performed with real-time US guidance, was completed in less than 5 minutes. (d) Repeat 90° lateral screen-film mammogram, which was obtained immediately after tissue sampling (in this case, fine-needle aspiration biopsy), shows that the mass is partially obscured by a small hematoma (arrow), with the suggestion of a small air-filled cavity at the aspiration site. Cytologic examination revealed malignant cells, which were suggestive of invasive lobular carcinoma. Histologic examination (subsequent breast-preservation surgery) showed invasive lobular carcinoma.

View larger version (139K): [in a new window]   Figure 23c. Imaging-guided tissue diagnosis: current. US-guided percutaneous biopsy is practical for any lesion that is depicted at US. (a) A 90° lateral screen-film mammogram shows a 6 x 8-mm noncalcified mass (arrow) with indistinct margins, which was nonpalpable even in retrospect. (b) Transverse sonogram shows the mass (arrow) to be oval and wider than tall, with minimally irregular margins, which confirms the mammographic suggestion of malignancy. (c) Transverse sonogram shows a biopsy needle (arrow) placed within the mass. This procedure, which was performed with real-time US guidance, was completed in less than 5 minutes. (d) Repeat 90° lateral screen-film mammogram, which was obtained immediately after tissue sampling (in this case, fine-needle aspiration biopsy), shows that the mass is partially obscured by a small hematoma (arrow), with the suggestion of a small air-filled cavity at the aspiration site. Cytologic examination revealed malignant cells, which were suggestive of invasive lobular carcinoma. Histologic examination (subsequent breast-preservation surgery) showed invasive lobular carcinoma.

View larger version (100K): [in a new window]   Figure 23d. Imaging-guided tissue diagnosis: current. US-guided percutaneous biopsy is practical for any lesion that is depicted at US. (a) A 90° lateral screen-film mammogram shows a 6 x 8-mm noncalcified mass (arrow) with indistinct margins, which was nonpalpable even in retrospect. (b) Transverse sonogram shows the mass (arrow) to be oval and wider than tall, with minimally irregular margins, which confirms the mammographic suggestion of malignancy. (c) Transverse sonogram shows a biopsy needle (arrow) placed within the mass. This procedure, which was performed with real-time US guidance, was completed in less than 5 minutes. (d) Repeat 90° lateral screen-film mammogram, which was obtained immediately after tissue sampling (in this case, fine-needle aspiration biopsy), shows that the mass is partially obscured by a small hematoma (arrow), with the suggestion of a small air-filled cavity at the aspiration site. Cytologic examination revealed malignant cells, which were suggestive of invasive lobular carcinoma. Histologic examination (subsequent breast-preservation surgery) showed invasive lobular carcinoma.

View larger version (142K): [in a new window]   Figure 24a. Imaging-guided tissue diagnosis: current. Stereotactic mammography provides imaging guidance for percutaneous biopsy of lesions not depicted at US, especially microcalcifications. (a) A 90° lateral screen-film mammogram shows a small cluster of microcalcifications (arrow). (b) Screen-film mammogram of core biopsy specimens documents removal of the targeted calcifications (arrow) in one core of tissue. A metallic clip was anchored in the breast through the biopsy needle to mark the core biopsy site because of the possibility that all of the microcalcifications were removed. This was done because a diagnosis of malignancy would require repeat excision to demonstrate tumor-free resection margins. (c) Repeat 90° lateral screen-film mammogram shows the clip placed at the site where (all) the calcifications were removed, which is also indicated by air within the biopsy cavity. Findings from biopsy showed DCIS. Repeat excision (subsequent breast-preservation surgery) revealed no residual carcinoma.

View larger version (107K): [in a new window]   Figure 24b. Imaging-guided tissue diagnosis: current. Stereotactic mammography provides imaging guidance for percutaneous biopsy of lesions not depicted at US, especially microcalcifications. (a) A 90° lateral screen-film mammogram shows a small cluster of microcalcifications (arrow). (b) Screen-film mammogram of core biopsy specimens documents removal of the targeted calcifications (arrow) in one core of tissue. A metallic clip was anchored in the breast through the biopsy needle to mark the core biopsy site because of the possibility that all of the microcalcifications were removed. This was done because a diagnosis of malignancy would require repeat excision to demonstrate tumor-free resection margins. (c) Repeat 90° lateral screen-film mammogram shows the clip placed at the site where (all) the calcifications were removed, which is also indicated by air within the biopsy cavity. Findings from biopsy showed DCIS. Repeat excision (subsequent breast-preservation surgery) revealed no residual carcinoma.

View larger version (135K): [in a new window]   Figure 24c. Imaging-guided tissue diagnosis: current. Stereotactic mammography provides imaging guidance for percutaneous biopsy of lesions not depicted at US, especially microcalcifications. (a) A 90° lateral screen-film mammogram shows a small cluster of microcalcifications (arrow). (b) Screen-film mammogram of core biopsy specimens documents removal of the targeted calcifications (arrow) in one core of tissue. A metallic clip was anchored in the breast through the biopsy needle to mark the core biopsy site because of the possibility that all of the microcalcifications were removed. This was done because a diagnosis of malignancy would require repeat excision to demonstrate tumor-free resection margins. (c) Repeat 90° lateral screen-film mammogram shows the clip placed at the site where (all) the calcifications were removed, which is also indicated by air within the biopsy cavity. Findings from biopsy showed DCIS. Repeat excision (subsequent breast-preservation surgery) revealed no residual carcinoma.

View larger version (81K): [in a new window]   Figure 25a. Imaging-guided tissue diagnosis: current. Current needle localization technique permits more precise needle placement, the anchoring of a localizing wire at the site of the needle, and therefore excision of a smaller biopsy specimen. (a) MLO screen-film mammogram demonstrates a 6 x 7-mm spiculated mass (arrow). (b) A 90° lateral screen-film mammogram shows a needle inserted into the mass (circled) through a fenestrated compression paddle. The alphanumeric grid markers on the compression paddle facilitate precise needle placement, which is done parallel to the x-ray beam (note air in the lumen of the needle). (c) CC screen-film mammogram (marked "right outer" to indicate the lateral aspect of the right breast), obtained after substitution of a hooked wire for the localizing needle, shows that the wire passes through the targeted mass (circled). (d) Screen-film radiograph of the excised biopsy specimen documents removal of the targeted mass (arrow). Findings from biopsy showed invasive ductal carcinoma, with no tumor present within 1 cm of the resection margins.

View larger version (67K): [in a new window]   Figure 25b. Imaging-guided tissue diagnosis: current. Current needle localization technique permits more precise needle placement, the anchoring of a localizing wire at the site of the needle, and therefore excision of a smaller biopsy specimen. (a) MLO screen-film mammogram demonstrates a 6 x 7-mm spiculated mass (arrow). (b) A 90° lateral screen-film mammogram shows a needle inserted into the mass (circled) through a fenestrated compression paddle. The alphanumeric grid markers on the compression paddle facilitate precise needle placement, which is done parallel to the x-ray beam (note air in the lumen of the needle). (c) CC screen-film mammogram (marked "right outer" to indicate the lateral aspect of the right breast), obtained after substitution of a hooked wire for the localizing needle, shows that the wire passes through the targeted mass (circled). (d) Screen-film radiograph of the excised biopsy specimen documents removal of the targeted mass (arrow). Findings from biopsy showed invasive ductal carcinoma, with no tumor present within 1 cm of the resection margins.

View larger version (162K): [in a new window]   Figure 25c. Imaging-guided tissue diagnosis: current. Current needle localization technique permits more precise needle placement, the anchoring of a localizing wire at the site of the needle, and therefore excision of a smaller biopsy specimen. (a) MLO screen-film mammogram demonstrates a 6 x 7-mm spiculated mass (arrow). (b) A 90° lateral screen-film mammogram shows a needle inserted into the mass (circled) through a fenestrated compression paddle. The alphanumeric grid markers on the compression paddle facilitate precise needle placement, which is done parallel to the x-ray beam (note air in the lumen of the needle). (c) CC screen-film mammogram (marked "right outer" to indicate the lateral aspect of the right breast), obtained after substitution of a hooked wire for the localizing needle, shows that the wire passes through the targeted mass (circled). (d) Screen-film radiograph of the excised biopsy specimen documents removal of the targeted mass (arrow). Findings from biopsy showed invasive ductal carcinoma, with no tumor present within 1 cm of the resection margins.

View larger version (172K): [in a new window]   Figure 25d. Imaging-guided tissue diagnosis: current. Current needle localization technique permits more precise needle placement, the anchoring of a localizing wire at the site of the needle, and therefore excision of a smaller biopsy specimen. (a) MLO screen-film mammogram demonstrates a 6 x 7-mm spiculated mass (arrow). (b) A 90° lateral screen-film mammogram shows a needle inserted into the mass (circled) through a fenestrated compression paddle. The alphanumeric grid markers on the compression paddle facilitate precise needle placement, which is done parallel to the x-ray beam (note air in the lumen of the needle). (c) CC screen-film mammogram (marked "right outer" to indicate the lateral aspect of the right breast), obtained after substitution of a hooked wire for the localizing needle, shows that the wire passes through the targeted mass (circled). (d) Screen-film radiograph of the excised biopsy specimen documents removal of the targeted mass (arrow). Findings from biopsy showed invasive ductal carcinoma, with no tumor present within 1 cm of the resection margins.