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Findings: Standard cranio-caudal (right,A & left,B) and medio-lateral oblique (right,C & left,D) mammographic images demonstrate marked breast atrophy, more notable on the left side. A large mass, measuring approximately 20 mm x 20 mm x 20 mm, is observed to occupy the upper-outer quadrant of the left breast. The mass contains a single focus of indeterminate-appearing calcification in its superior-lateral aspect. Scattered, sparse, benign-appearing calcifications are noted bilaterally.

Diagnosis: Left breast mass, highly suspicious for malignancy.

Discussion: This case nicely illustrates two of the cardinal ("primary") mammographic signs that raise suspicion for malignancy. These relate to the density and, more importantly, to the contour of the lesion in question.

Density - the lesion is of relatively high-density radiopacity; a very large minimal amount of superimposed breast parenchymal tissue may be visualized "through" the lesion.

Contour - the periphery of the lesion is irregular and only vaguely definable; the border is densely spiculated, in the classical "stellate" pattern.

The size of the lesion, although ominous in appearance, is of lesser importance in the mammographic determination of malignancy in this case, without the benefit of previous studies to allow for the assessment of rate of tumor growth. The size, form, and pattern of breast parenchymal calcifications in this study do not play a contributing role in the mammographic determination of malignancy, owing to their benign appearance.

The patient was referred for biopsy of the lesion, on the basis of the criteria as described above. The pathological identity of the lesion, as well as the potential for metastasis to skeletal sites as alluded to in the clinical data, shall be the grounds for future case presentation and discussion.

Differential Diagnosis: Two other entities which must be considered in regard to this study are post-operative changes, including hematoma, and sclerosing duct hyperplasia ("radial scar").

Post-op changes - not a consideration, as the patient has not undergone surgery or other interventional procedure at this location.

Sclerosing duct hyperplasia - likewise, an unlikely possibility, given the presence of a central tumor mass, and its "consistent" appearance on orthogonal views of the left breast.

References:
1. Kopans DB, Breast Imaging. JB Lippincott Company, Philadelphia, 1989.

2. Lindfors KK. Breast imaging. In: Fundamentals of Diagnostic Radiology,
WE Brant and CA Helms, eds., pages 525-556. Williams & Wilkins.

3. Tabar L and Dean PB: Teaching Atlas of Mammography,
2nd edition. Thieme, Inc., New York, 1985.

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