Signs of Breast Cancer Beyond Calcifications on Mammography and Ultrasound
Breast cancer can present with multiple imaging and clinical findings beyond calcifications on mammography and abnormalities on ultrasound, including masses, architectural distortion, asymmetries, and skin/nipple changes that should be thoroughly evaluated for early detection.
Mammographic Signs of Breast Cancer
Mammography remains the primary screening tool for breast cancer detection. Beyond calcifications, several other important mammographic findings may indicate malignancy:
Masses
- Spiculated masses (highly suggestive of malignancy with ≥95% probability) 1
- Irregular or ill-defined masses
- Masses with indistinct margins
- High-density masses compared to surrounding tissue
Architectural Distortion
- Distortion of normal breast parenchymal pattern without a visible mass
- Speculations radiating from a point
- Focal retraction or distortion of the edge of the breast
Asymmetries
- Focal asymmetry (visible on two projections but lacks the borders and conspicuity of a true mass)
- Global asymmetry (asymmetry of fibroglandular tissue greater in volume in one breast compared to the corresponding area in the contralateral breast)
- Developing asymmetry (new or enlarging asymmetry compared with previous mammograms)
Ultrasound Signs of Breast Cancer
Ultrasound is complementary to mammography and can detect additional findings:
- Hypoechoic solid masses with irregular margins
- Masses with posterior acoustic shadowing
- Masses with microlobulated or angular margins
- Masses taller than wide (non-parallel orientation)
- Disruption of tissue planes
- Increased vascularity on Doppler imaging
MRI Signs of Breast Cancer
MRI has an established role in specific situations:
- Rapid enhancement with washout kinetics
- Irregular or spiculated masses
- Non-mass enhancement in a ductal or segmental distribution
- Rim enhancement
- Restricted diffusion
According to ESMO guidelines, MRI is not routinely recommended but may be considered in cases of:
- Familial breast cancer associated with BRCA mutations
- Breast implants
- Lobular cancers
- Before neoadjuvant chemotherapy
- When findings of conventional imaging are inconclusive 1
Clinical Signs of Breast Cancer
Physical examination remains crucial and may reveal:
- Palpable breast lumps (though DCIS presenting as a palpable mass is unusual) 1
- Nipple discharge (especially spontaneous, unilateral, and bloody)
- Nipple retraction or inversion
- Skin changes (dimpling, peau d'orange, erythema)
- Axillary lymphadenopathy
- Breast asymmetry
BI-RADS Classification System
The BI-RADS system provides standardized reporting of mammographic findings:
- Category 1: Negative (symmetric breasts with no masses, architectural distortion, or suspicious calcifications)
- Category 2: Benign findings (calcifying fibroadenomas, oil cysts, lipomas)
- Category 3: Probably benign findings (<2% risk of malignancy)
- Category 4: Suspicious abnormality (wide range of probability of malignancy)
- Category 5: Highly suggestive of malignancy (≥95% probability)
- Category 6: Known biopsy-proven malignancy 1
Diagnostic Approach
When suspicious findings are detected:
- Additional mammographic views (magnification, spot compression) should be performed for better characterization
- Ultrasound should be performed for any palpable mass, even if mammographically negative 1
- Core needle biopsy (stereotactic or ultrasound-guided) for tissue diagnosis
- MRI may be considered in specific situations as mentioned above
Important Considerations
- Mammography may underestimate the extent of breast cancer, particularly DCIS 1
- Approximately 10% of mammographically evident DCIS will be without calcifications 1
- Double reading of mammograms increases sensitivity by 5-15% 1
- Supplemental ultrasound screening in women with dense breasts can detect additional cancers missed on mammography 2
- The addition of screening ultrasound to mammography in women at increased risk results in higher cancer detection yield but also increases false-positive findings 2
Pitfalls to Avoid
- Do not dismiss a palpable mass even if imaging is negative
- Do not use early recall as a substitute for adequate assessment 1
- Remember that peritumoral inflammation or fibrosis can cause a mass to be present along with microcalcifications 1
- Be aware that imaging techniques cannot reliably determine whether the basement membrane has been violated (invasive vs. in situ disease) 1
- Approximately 20% of DCIS diagnosed on core needle biopsy will have areas of invasive carcinoma found at surgical excision 1
By understanding and recognizing these various signs of breast cancer beyond calcifications, clinicians can improve early detection rates and potentially reduce breast cancer mortality.