Dr Hipolito, Radiologist

CASE REPORT: A 50-year-old asymptomatic woman presented for routine two-yearly mammogram.

There is an irregular solid lesion with suspicious sonographic features in the right breast 12 o’clock position.

The biopsy procedure was done under ultrasound guidance using a standard 14-gauge biopsy needle.

The biopsy confirmed an invasive lobular carcinoma, ER and PR positive and HER2 negative. She underwent mastectomy, axillary clearance and reconstruction.


Breast density may be reported as percentage visually, using BIRADS lexicon, and can be classified into four categories:

  • Less than 25% fibroglandular density = almost entirely fatty
  • 26-50% fibroglandular density = scattered fibroglandular tissue
  • 51-75% fibroglandular density = heterogeneously dense
  • More than 75% fibroglandular = extremely dense

Visual designation of breast density may be subjective, inconsistent and not reproducible due to inter-observer and intra-reader variability.

Volpara is a volumetric breast density measurement tool, software used to help radiologists assess breast density more objectively (Volpara Density Grade is usually stated in the patient’s radiology report).

Ultrasound use

Being radiation free, it is the first imaging of choice for pregnant and breastfeeding women and for symptomatic patients aged < 35 years.

Breast ultrasound has long been a diagnostic tool in evaluating mammographic abnormalities and for evaluation of clinical abnormality or symptoms of any age and gender.

It is also commonly used to evaluate women with past history of breast cancer, breast implants and for image guided biopsy or other minimally invasive breast procedures.

Ultrasound can detect invasive breast cancer before it becomes clinically evident. Adding ultrasound to mammography makes a lot of sense, particularly in women with dense breasts. In women with dense breast tissue, several clinical studies have demonstrated that breast ultrasound can pick up both clinically and mammographically occult breast cancer.

However, no trials have proven a mortality benefit of this imaging modality. False positives are significant, reducing with succeeding ultrasounds in a surveillance series.

Breast ultrasound does not replace mammography in evaluation of breast calcifications, asymmetric densities and architectural distortions.

Mammogram and ultrasound are complementary imaging modalities and one does not replace the other.

Biopsy use

The standard of care for clinically, mammographically or sonographically detected breast lesions is to perform needle test (Triple Test Assessment) either an image-guided fine needle aspiration or core biopsy – for diagnosis and to guide further management.

Digital breast tomosynthesis (DBT), or 3D tomosynthesis, is an advanced mammography technique. It is a new technology, an accepted adjunct to the standard 2D mammogram, now used in screening and diagnostic centres both locally and internationally.

Several clinical trials indicate DBT improves cancer detection rates, decreases recall rates (especially in women with dense breast tissue) and reduces the number of unnecessary biopsies. Its suitability for all patients, regardless of age or breast tissue type, comes from its better visualisation and characterisation of masses, distortions and asymmetric densities. High risk patients benefit from DBT, including those with a strong family history of breast or ovarian cancers or those with a first degree male relative with prostrate or breast cancer, and those with dense breasts. Those with previous breast disease/cancer and those requiring further assessment following a 2D mammogram also benefit.

In DBT, the X-ray tube moves through an arc while acquiring a series of low-dose images and then converted into a stack of thin slices, typically 1 mm thick – combined 2D and 3D study images increase patient radiation by about twofold but still within safety limits and similar to the traditional film-screen mammogram studies. According to researchers, 2D-image generating software may replace the conventional 2D mammogram and potentially reduce the radiation dose by up to 45%.

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