Gamuts in Radiology (Breast)

COMMON
1. Axillary lymph node (eg, lymphoma G; leukemia ; metastasis; tuberculosis) (See I-17)
2. Carcinoma (esp. mucinous or papillary)
3. Cyst
4. Fibroadenoma
5. Fibrocystic change (esp. sclerosing adenosis)
*6. Intramammary lymph node
*7. Oil or lipid cyst (posttraumatic or postsurgical fat necrosis)
8. Papilloma , papillomatosis
9. Skin lesion (eg, wart; mole ; neurofibroma ; sebaceous cyst; nipple out of profile)


UNCOMMON
*1. Galactocele
2. Hemangioma (cavernous)
*3. Hematoma or seroma
*4. Lipoma
5. Metastasis
6. Phyllodes tumor (formerly cystosarcoma phyllodes)

COMMON
1. Carcinoma (unusual to be circumscribed at this size)
2. Cyst (simple or complicated)


UNCOMMON
1. Abscess
2. Axillary or unusual intramammary lymphadenopathy (eg, lymphoma G, metastasis) (See I-17)
*3. Fibroadenolipoma (hamartoma)
4. Hematoma
*5. Lipoma
6. Metastasis to breast
*7. Oil or lipid cyst, large (posttraumatic or postsurgical fat necrosis)
8. Phyllodes tumor (formerly cystosarcoma phyllodes; giant fibroadenoma)
9. Postoperative seroma (eg, after implant removal-usually not well circumscribed)
10. Sarcoma
11. [Sebaceous cyst]


*Radiolucent or partially lucent lesions containing fat.

[ ] This condition does not actually cause the gamuted imaging finding, but can produce imaging changes that simulate it.

COMMON
1. Carcinoma, usually not "well" circumscribed on magnification views (eg, ductal in situ; invasive ductal; medullary; colloid or mucinous ; papillary; intracystic papillary)
*2. Cyst
*3. Fibroadenoma
*4. Fibrocystic change (esp. sclerosing adenosis)
5. Intramammary (or axillary) lymph node
6. [Normal variant (circumscribed parenchyma of puberty; retracted or normal nipple out of profile ; end-on vein)]
7. Oil or lipid cyst (posttraumatic or postsurgical fat necrosis)
*8. Papilloma (intraductal)
*9. [Skin lesion (eg, mole; wart; neurofibroma ; epidermal inclusion or sebaceous cyst)]


UNCOMMON
1. Abscess
*2. Fibroadenolipoma (hamartoma)
3. Galactocele
4. Granular cell myoblastoma
5. Hemangioma (cavernous)
6. Hematoma
7. Lipoma
8. Lymphoma, primary
*9. Metastasis to breast (eg, from melanoma; carcinoma of lung, ovary, GI or GU tract; lymphoma G; sarcoma)
10. Phyllodes tumor (formerly cystosarcoma phyllodes; giant fibroadenoma)
11. Pseudoangiomatous stromal hyperplasia (PASH)
12. Sarcoma of breast (eg, angiosarcoma)
*13. [Silicone or paraffin globule or implant artifact]


* May be multiple.

[ ] This condition does not actually cause the gamuted imaging finding, but can produce imaging changes that simulate it.

COMMON
1. Cyst
2. Fibroadenoma
3. Fibrocystic change (solid nodule)
4. Mole or skin tag (halo usually incomplete)
5. Sebaceous cyst


UNCOMMON
1. Carcinoma (intracystic, medullary, papillary)
2. Fibroadenolipoma (hamartoma)

COMMON
*1. Carcinoma (esp. scirrhous; invasive ductal ; invasive lobular ; medullary; mucinous; papillary)
*2. Fat necrosis (traumatic; postsurgical; postbiopsy scar; idiopathic)
*3. Fibrocystic change (esp. sclerosing adenosis)
4. [Superimposed densities or summation shadows creating a "pseudomass"]


UNCOMMON
*1. Abscess, acute or chronic
2. Complicated cyst (hemorrhagic, inspissated, or infected)
*3. Fibroadenoma (hyalinized)
*4. Fibromatosis (extra-abdominal desmoid)
5. Foreign body granuloma (eg, suture)
*6. Granular cell myoblastoma
7. Hematoma
8. Lymphoma G
9. Plasma cell mastitis
*10. Radial scar (complex sclerosing lesion)
11. Sarcoma
12. Tuberculosis ; fungus disease; nocardiosis


*May present as a spiculated lesion.

[ ] This condition does not actually cause the gamuted imaging finding, but can produce imaging changes that simulate it.

COMMON
1. Carcinoma (esp. scirrhous infiltrating ductal; also tubular, invasive lobular , intraductal )
2. Fat necrosis (traumatic; postsurgical; postbiopsy scar; idiopathic)
*3. Radial scar (sclerosing duct hyperplasia; complex sclerosing lesion; indurative mastopathy)
4. Scarring (posttraumatic; postoperative )
5. [Summation shadows]


UNCOMMON
1. Abscess (occasionally)
2. Fibroadenoma, hyalinized with fibrosis and myxoid degeneration
3. Fibrocystic change (esp. sclerosing adenosis)
4. Fibromatosis (extra-abdominal desmoid)
5. Granular cell myoblastoma


* Associated carcinoma of breast is present in about 25% of radial scars (20% in situ, 5% invasive carcinoma).

[ ] This condition does not actually cause the gamuted imaging finding, but can produce imaging changes that simulate it.

COMMON
1. Intramammary lymph node
2. Lipoma
3. Normal fat lobule
4. Oil or lipid cyst (posttraumatic or postsurgical fat necrosis )
5. Radial scar (central lucency)


UNCOMMON
1. Fibroadenolipoma (hamartoma)
2. Galactocele
3. Hematoma, acute (fat-fluid level)
4. Liposarcoma
5. Steatocystoma (simplex or complex)

COMMON
1. Cyst (simple)
2. [Ultrasound equipment, malfunctioning or with very incorrect settings]


UNCOMMON
1. Fibroadenoma (rarely)
2. Lymphoma G: leukemia


[ ] This condition does not actually cause the gamuted imaging finding, but can produce imaging changes that simulate it.

COMMON
1. Abscess
2. Carcinoma
3. Cyst, complicated (proteinaceous; punctured by partial needle aspiration; inflammatory ; infected; mildly hemorrhagic)
4. Fibroadenoma
5. Fibrocystic change
6. Intramammary lymph node
7. Papilloma
8. Sebaceous cyst


UNCOMMON
1. Keratinaceous cyst
2. Lactational adenoma
3. Lymphoma G; leukemia
4. Phyllodes tumor (formerly cystosarcoma phyllodes; giant fibroadenoma)
5. Pseudoangiomatous stromal hyperplasia (PASH)
6. Steatocystoma (simplex or complex)
7. Superficial thrombophlebitis (Mondor's disease)
8. Tubular adenoma

COMMON
1. Carcinoma (calcified)
2. Fat necrosis (traumatic; postsurgical; postbiopsy scar; idiopathic)
3. Fibroadenoma (calcified)
4. [Metallic or other artifact; biopsy marker; foreign body]
5. "Milk of calcium" crystals in cyst fluid (dependent crystal layer is hyperechoic)
6. Scarring with or without scar calcification
7. Silicone extravasation (leakage or rupture)


UNCOMMON
1. Lipoma
2. Cyst, complex (inspissated, hemorrhagic)


[ ] This condition does not actually cause the gamuted imaging finding, but can produce imaging changes that simulate it.

COMMON
1. Carcinoma with central necrosis
2. Fat necrosis (traumatic ; postsurgical; postbiopsy scar; idiopathic)
3. Fibroadenoma (bizarre or popcorn-like calcifications)


UNCOMMON
1. Granulomatous disease (tuberculosis, fungus disease, usually in axillary lymph nodes)
2. Renal osteodystrophy (secondary hyperparathyroidism); hypercalcemia

COMMON
1. Calcified sebaceous gland cysts ; other skin lesions
2. Fibroadenoma
3. Fibrocystic change
4. Oil or lipid cyst (posttraumatic or postsurgical fat necrosis)


UNCOMMON
1. Galactocele (in capsule)
2. Lipoma with fat necrosis
3. Liponecrosis microcystica calcificans (subcutaneous fat necrosis)
4. Panniculitis nodularis, nonsuppurative (Weber-Christian disease)
5. Papilloma
6. Plasma cell mastitis* (periductal mastitis; also known as secretory disease)
7. Postradiation therapy (dystrophic round or ring-like calcifications)
8. Silicone or paraffin globules


* May occasionally show dense, regular, elongated, linear or branching intraductal calcifications as well as more common large, smooth, dense, round, or oval calcifications.

(Homogeneous, Solid, Well-Defined, Spherules or Pearls in Dilated Ductules and Lobules)

1. Atypical lobular hyperplasia
2. Blunt duct adenosis
3. Fibrocystic change (esp. sclerosing adenosis) with "milk of calcium" crystals in cyst fluid


* Homogeneous, solid, well-defined, spherules or pearls in dilated ductules and lobules

COMMON
1. Arterial (Mönckeberg's medial sclerosis and atherosclerosis)
2. Carcinoma (intraductal)
3. Fibrocystic change with "milk of calcium" crystals in cyst fluid
*4. Plasma cell mastitis (periductal mastitis; secretory disease)


UNCOMMON
1. Parasites (Loa Loa ; Dracunculus medinensis (guinea worm) (serpiginous outline in subcutaneous tissues of breast)


* May occasionally show dense, regular, elongated, linear, or branching intraductal calcifications as well as more common large, smooth, dense, round, or oval calcifications.

1. Carcinoma, intraductal (may present as (a) casts of the ductal lumen, or as (b) tiny granular, dot-like or elongated, multiple, irregularly grouped microcalcifications very close together)
2. Carcinoma (lobular in situ)
3. Early calcification within a fibroadenoma or artery
4. Fibrocystic change (sclerosing adenosis)
5. Papilloma ; papillomatosis (intraductal)
6. Scar calcification (fat necrosis )

1. [Artifacts or pseudocalcifications from powders, creams, ointments, or deodorants on skin surface of breast or axilla]
2. Atrophic
3. Carcinoma (intraductal or multicentric lobular)
4. Fibrocystic change (esp. sclerosing adenosis)
5. Involutional glandular
6. Plasma cell mastitis* (secretory disease; periductal mastitis; ductal ectasia)


* May occasionally show dense, regular, elongated, linear, or branching intraductal calcifications as well as more common large, smooth, dense, round or oval calcifications.

[ ] This condition does not actually cause the gamuted imaging finding, but can produce imaging changes that simulate it.

COMMON
1. Carcinoma (intraductal)
2. [Dense breast]
3. Ductal ectasia; periductal inflammation and fibrosis
4. Lactation
5. Papilloma (solitary or multiple, intraductal)
6. Papillomatosis (intraductal)


UNCOMMON
1. Ductal adenoma
2. Ductal hyperplasia


[ ] This condition does not actually cause the gamuted imaging finding, but can produce imaging changes that simulate it.

COMMON
1. Carcinoma (intraductal)
2. [Dense breast]
3. Ductal ectasia; periductal inflammation and fibrosis
4. Lactation
5. Papilloma (solitary or multiple, intraductal)
6. Papillomatosis (intraductal)


UNCOMMON
1. Ductal adenoma
2. Ductal hyperplasia


[ ] This condition does not actually cause the gamuted imaging finding, but can produce imaging changes that simulate it.

COMMON
1. Carcinoma , esp. scirrhous (locally advanced with focal skin thickening, or recurrent after lumpectomy and radiation therapy)
2. Fluid overload, systemic (eg, heart failure ; renal failure; anasarca; hypoalbuminemia; cirrhosis)
3. "Inflammatory" carcinoma (neoplastic lymphatic obstruction)
4. Lymphatic obstruction (eg, following axillary node dissection or secondary to axillary or mediastinal nodal metastases from breast or other primary malignancy)
5. Mastitis (incl. bacterial, fungal, tuberculous , filarial infection)
6. Postoperative (recent); postbiopsy; reduction mammoplasty
7. Radiation therapy


UNCOMMON
1. Abscess (esp. retromammary)
2. Burn
3. Fat necrosis and interstitial hematoma (incl. Coumadin therapy)
4. Insect bite (usually spider )
5. Lymphoma G
6. Metastatic disease to breast (esp. from opposite breast)
7. Pachydermoperiostosis

1. Fat necrosis (oil or lipid cyst, posttraumatic or postsurgical)
2. Film or screen artifacts (scratches , fingerprints)
3. Foreign substance on skin surface (eg, medicinal ointment; bandage; axillary deodorant )
4. Lymph nodes (in axilla, axillary tail of breast, or intramammary )
5. Lymphedema (eg, obstruction of lymph drainage from metastases or surgery; heart failure)
6. Nipple out of profile ; retracted nipple
7. Postbiopsy scar
8. Silicone or paraffin injection
9. Skin calcifications
10. Skin lesion (eg, wart; mole ; neurofibroma ; sebaceous or epidermal inclusion cyst)
11. Superimposition of fibroglandular breast tissue

COMMON
1. Accessory breast tissue (no atypical features)
2. Arterial calcification (parallel calcifications; Mönckeberg's calcification)
3. Fat necrosis (with characteristic rim calcification)
4. Fibroadenoma, involuting (with characteristic calcification such as shell or popcorn)
5. Fibroadenolipoma (hamartoma)
6. Intramammary lymph node (normal size, shape, and density; fatty lucency centrally)
7. Milk of calcium crystals (calcifications layering concave up on true lateral view)
8. Oil cyst (posttraumatic fat necrosis, fatty lucency centrally)
9. Hematoma (history of blunt trauma such as motor vehicle accident, seat belt or steering wheel injury--not infected)
10. Raised skin lesion (eg, verrucous wart; seborrheic keratosis)
11. Secretory calcifications (plasma cell mastitis--rod shaped calcifications larger than 0.5 mm thick)
10. Skin calcifications (size less than 0.5 mm; rim calcification with lucent center)


UNCOMMON
1. Cyst with rim or wall calcification
2. Galactocele
3. Lipoma


* These lesions can only be safely ignored if they have been confidently diagnosed by an experienced radiologist based on the lesion's appearance and characteristic features and the patient is asymptomatic.

PHYSIOLOGICAL
*1. Idiopathic
2. Neonatal (high placental estrogens)
3. Pubertal (excess of estradiol over testosterone)
*4. Senile (falling androgen and rising estrogen levels with age)


PHARMACOLOGICAL
1. Anti-androgens (eg, spironolactone)
2. Antidepressants, tricyclic
*3. Chemotherapy drugs (producing testicular damage)
4. Digitalis (binds to estrogen receptors)
*5. Estrogen (esp. in prostate cancer treatment)
6. Methyldopa
7. Phenothiazines
8. Reserpine


PATHOLOGICAL
1. Bronchogenic carcinoma (secreting HCG)
2. Cirrhosis (increased conversion of androgens to estrogens)
3. Estrogen secreting tumor (eg, adrenal tumor; Leydig cell tumor)
4. Hyperthyroidism
*5. Hypogonadism (eg, castration; Klinefelter S. {XXY S.})
6. Hypopituitarism (incl. acromegaly)
7. Hypothyroidism, infantile (cretinism)
8. Testicular feminization (androgen insensitivity)
9. Testicular tumor (eg, teratoma secreting HCG)


SYNDROMES
1. Cowden S. (multiple hamartoma S.)
2. Gorlin S. (nevoid basal cell carcinoma S.)
3. Paraneoplastic syndromes


* Common.

COMMON
1. Dermatopathic (psoriatic arthritis , rheumatoid arthritis)
2. Lymphoma G; leukemia
3. Metastatic disease from breast primary (also can be mimicked by primary breast carcinoma involving accessory breast parenchyma in axilla)
4. Tuberculosis or fungus disease (may calcify)


UNCOMMON
1. Langerhans cell histiocytosis G
2. Metastatic disease, other (eg, from melanoma; carcinoma of lung or ovary)

COMMON
1. Inadequate or improper positioning
2. Muscular dystrophy
3. Normal variant
4. Prior surgery injuring pectoralis with atrophy (eg, multiple difficult implant placements and removals with or without silicone extravasation)
5. Stroke
6. Trauma (esp. in childhood)


UNCOMMON
1. Poland syndrome (pectoral muscle aplasia-syndactyly)
2. Poliomyelitis

. Reading mammograms under poor viewing conditions:
a. With any room light reflected off films (overhead lights, lamps, hallway, other viewboxes)
b. Without large, good quality magnifier
c. With regular viewbox or dim light source (strong light source needed for mammogram reading)
2. Assuming a lesion is benign (especially a nodule) based on screening films only without proper workup (eg, magnification views or ultrasound).
3. Recommendation for biopsy of benign milk of calcium crystals due to failure to perform true lateral views or magnification views.
4. Mistaking a hypoechoic mass for an anechoic cyst on ultrasound. Many solid lesions including carcinomas can appear as hypoechoic masses with acoustic enhancement.
5. Failure to recommend biopsy for a carcinoma because it was thought to be a benign radial scar.
6. Incomplete or inaccurate assessment of a palpable lesion due to failure to correlate the palpable area with the imaging findings (esp. during ultrasound).
7. Failure to recognize microcalcification pattern of DCIS when there is no associated mass density.
8. Calling a patient back or recommending biopsy for the muscle shadow sometimes seen medially on the CC view (sternalis muscle or medial extension of the pectoralis muscle).
9. Correct assessment of the margins of a nodule or mass as poorly circumscribed, circumscribed, or well circumscribed. Also halo versus moat distinction.
10. Failure to do an axillary view for abnormal lymph nodes during diagnostic workup of a probable carcinoma in the breast.
11. Recommend unnecessary workup or biopsy due to failure to recognize benign axillary or intramammary lymph node characteristics.
12. Failure to make diagnosis of lymphadenopathy due to not looking in axillary region or not recognizing signs of lymph node abnormalities.
13. Failure to spot an early breast cancer developing when multiple bilateral lesions are present (nodules, calcification clusters, or both).
14. Recommending unnecessary biopsy of posttraumatic or postbiopsy fat necrosis.
15. Attempting to biopsy dermal calcifications due to failure to obtain tangential views.
16. Leaving the tip of the localization wire short or proximal to the lesion due to bad positioning or use of a needle that is insufficiently long.
17. Calling a patient back or recommending biopsy of a lesion which appears to be an interval change on comparison to one prior mammogram when review of older mammograms show the lesion is actually unchanged for years.
18. Recommending biopsy of a complicated cyst because the gauge of the needle used for aspiration was too small and no fluid was drained. Some complicated cysts require an 18 gauge needle and a 10 cc syringe to aspirate thick or inspissated fluid, mucin, or grummous contents.
19. False ultrasound diagnosis of a hypoechoic lesion in the retroareolar region due to shadowing caused by the skin of the nipple and areola.
20. Absent, vague, or indecisive recommendation in written report leading to failure or delay of patient or physician to proceed to the next appropriate procedure. One common example is the ultrasound report which ends with just the impression "complicated cyst" without giving a specific recommendation such as biopsy or aspiration.
21. Failure to call a patient back or recommend biopsy of a lesion which appears to be stable on comparison to prior mammograms over a less than 3 year interval when it is actually an indolent carcinoma (esp. DCIS).
22. Calling a patient back or recommending biopsy for a false microcalcification cluster due to a fingerprint or scratch artifact.
23. Failure to notice unilateral diffuse increase in breast density due to widespread malignancy such as inflammatory carcinoma.
24. Interventional biopsy of the wrong lesion due to the presence of multiple lesions. This most often occurs when a partial field preliminary view is done which happens to make a second area look like the area of concern when actually the area of concern is outside the field of view.

1. Films too light due to technique or poor compression.
2. Doing routine screening without carefully reviewing images before letting patient leave. This is especially true for mammography certified technologists (R.T.(M)) whose special training allows them to aid in the detection of breast cancer.
3. Failure to mark skin mole or other skin lesion leading to callback of the patient for workup of possible breast nodule.
4. Failure to mark the site of scars on the patient history sheet and/or on the skin leading to unnecessary patient recall.
5. Failure to obtain nipple profile view when nipple not profiled on either CC or MLO view.
6. Failure to do at least one magnification view for possible microcalcification cluster.
7. Poor or no visualization of the pectoralis muscle on the MLO view indicating failure to adequately show the upper outer quadrant and axillary region.
8. Exclusion of posterior breast tissue due to poor positioning (inadequate posterior nipple line distance).
9. Failure to do spot compression view for possible architectural distortion in dense tissue.
10. Failure to notice and correct artifacts on screens which can simulate microcalcification clusters.
11. Failure to show a lesion located near the skin (esp. within 1 cm of the skin) with ultrasound. Good imaging of nearfield lesions often needs special focusing, or the use of an offset pad or waterbath attachment.
12. Adding excessive fluid or failing to drain excessive fluid from breast biopsy specimens (esp. core biopsies) prior to specimen radiography.