Diagnostic Mammography + Tomosynthesis

Diagnostic mammography is the targeted evaluation of a symptomatic breast or of a finding recalled from screening. It combines standard projections with problem-solving views such as spot compression and magnification, and increasingly with digital breast tomosynthesis (DBT), which reduces tissue overlap and improves lesion characterisation. Findings are described and managed using the BI-RADS lexicon and assessment categories.

Indications

Palpable breast lump or focal area of clinical concern
Workup of an abnormality recalled from screening mammography
Focal, non-cyclical breast pain or skin and nipple changes
Spontaneous single-duct or bloody nipple discharge
Short-interval follow-up of a probably benign lesion and surveillance of treated breast cancer

Contraindications & Cautions

Pregnancy is a relative consideration; diagnostic mammography may still be performed with shielding when clinically necessary, often after ultrasound
No absolute contraindication in symptomatic patients where benefit outweighs the low dose
Ultrasound is preferred as the first test in women under about 30 and during lactation
Recent breast surgery or infection may limit compression tolerance

Patient Preparation

Take a focused history of symptoms, prior surgery, hormone use and family history
Mark palpable lumps, scars and the area of concern with a radiopaque skin marker
Advise avoiding deodorant, powder or lotion that can mimic calcifications
Retrieve prior mammograms for comparison
Explain compression and its role in reducing dose and motion

Technique & Parameters

Standard craniocaudal (CC) and mediolateral oblique (MLO) projections of the symptomatic breast
Digital breast tomosynthesis acquired to reduce overlapping tissue and better define margins
Spot compression views to disperse overlapping tissue and confirm or exclude a mass or distortion
Magnification views (with spot compression) to characterise the morphology and distribution of calcifications
Additional projections (true lateral, rolled CC, exaggerated CC, cleavage) to localise and confirm findings
Correlate with targeted ultrasound and proceed to image-guided biopsy for suspicious findings

Systematic Review

Compare with prior studies and assess overall breast density
Search each view systematically for masses, calcifications, asymmetry and architectural distortion
Characterise masses by shape, margin and density
Characterise calcifications by morphology and distribution
Correlate the mammographic finding with the site of clinical concern and with ultrasound
Assign a BI-RADS assessment category and management recommendation

Key Findings & Significance

Spiculated high-density mass or architectural distortion suggests invasive carcinoma
Fine pleomorphic or fine linear branching calcifications in a segmental or linear distribution suggest DCIS or invasive disease
Circumscribed oval mass suggests a benign lesion such as fibroadenoma or cyst (correlate with ultrasound)
Coarse popcorn-like calcification is typical of an involuting fibroadenoma
A developing or enlarging focal asymmetry warrants further assessment
Skin thickening and trabecular coarsening may indicate inflammatory carcinoma or oedema

Differential Considerations

Spiculated mass: invasive carcinoma, radial scar, post-surgical scar or fat necrosis
Circumscribed mass: cyst, fibroadenoma, phyllodes tumour, or circumscribed carcinoma
Suspicious calcifications: DCIS versus fibrocystic change, fat necrosis or fibroadenoma
Architectural distortion: carcinoma, radial scar, prior surgery or benign sclerosing lesion
Focal asymmetry: summation artefact, fibroglandular tissue, or an underlying mass

Pearls & Pitfalls

Tomosynthesis increases cancer detection and reduces recall by unmasking distortion hidden by overlap
Magnification views are essential to characterise calcification morphology and extent
A palpable lump with negative mammography still requires ultrasound and clinical correlation (triple assessment)
Always seek a summation artefact explanation for a focal asymmetry with spot compression before recall
Assign an explicit BI-RADS category as it drives the management recommendation

Structured Report

State the views and whether tomosynthesis and problem-solving views were performed
Report breast density and describe findings using the BI-RADS lexicon
Give the location, size and characteristics of any mass, calcifications or distortion
Correlate with ultrasound and clinical findings
Assign a final BI-RADS category (0-6) with a clear management recommendation such as biopsy or follow-up

References

ACR BI-RADS Atlas, 5th Edition (Breast Imaging Reporting and Data System)
ACR Practice Parameter for the Performance of Diagnostic Mammography
Vedantham S et al. Digital Breast Tomosynthesis: State of the Art. Radiology
Sickles EA. Breast Imaging: From 1965 to the Present. Radiology

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.

Diagnostic Mammography + Tomosynthesis

📋 Indications

⛔ Contraindications & Cautions

🧑‍⚕️ Patient Preparation

⚙️ Technique & Parameters

🔎 Systematic Review

🩻 Key Findings & Significance

🧠 Differential Considerations

💡 Pearls & Pitfalls

📝 Structured Report

📚 References