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Breast
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Breast Imaging Overview
Breast Density
Breast Density
Wendie A. Berg, MD, PhD, FACR, FSBI
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KEY FACTS

  • Terminology

    • Imaging

      • Pathology

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • BI-RADS defines 4 categories of breast density (A-D)
              • Recommended but not required in mammogram report
              • Density inform laws may require inclusion of breast density in lay mammogram results letters to patients (depending on state law)
              • Category A: Almost entirely fatty
              • Category B: Scattered areas of fibroglandular density
                • Some cancers can be obscured even with only scattered density
              • Category C: Heterogeneously dense, which may obscure small masses
                • Some areas of parenchyma dense, others mostly fatty
                • In dense areas, noncalcified masses can be masked
                • Even if only 1 quadrant dense, categorize as heterogeneously dense
              • Category D: Extremely dense, which lowers sensitivity of mammography
                • Nearly entire breast shows dense tissue except for subcutaneous fat
            • Dense breasts: Heterogeneously or extremely dense
            • Nondense breasts: Fatty or scattered
            • Subareolar density (due to normal ducts and ligaments) in isolation not usually included as "dense"
            • Interval cancer: Detected clinically in interval between prescribed mammographic screens
            • Fibroglandular tissue (FGT): Terminal duct lobular units (TDLUs), ducts, stroma, ligaments
            • Quantitative software programs can measure percent mammographic density (PMD) in 2 dimensions (area) or 3 dimensions [volumetric breast density (VBD)]
              • Even densest breast tissue only ~ 35% dense by volume when quantified

          IMAGING

          • General Features

            • Mammographic Findings

              • Ultrasonographic Findings

                • MR Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      PATHOLOGY

                      • Microscopic Features

                        • Receptor Studies

                          CLINICAL ISSUES

                          • Presentation

                            • Demographics

                              • Natural History & Prognosis

                                • Treatment

                                  DIAGNOSTIC CHECKLIST

                                  • Consider

                                    • Image Interpretation Pearls

                                      • Reporting Tips

                                        Selected References

                                        1. Brentnall AR et al: Long-term Accuracy of Breast Cancer Risk Assessment Combining Classic Risk Factors and Breast Density. JAMA Oncol. e180174, 2018
                                        2. Chowdhury M et al: Dose-dependent effect of mammographic breast density on the risk of contralateral breast cancer. Breast Cancer Res Treat. ePub, 2018
                                        3. Moshina N et al: Automated volumetric analysis of mammographic density in a screening setting: worse outcomes for women with dense breasts. Radiology. 288(2):343-352, 2018
                                        4. Raj SD et al: Deciphering the Breast Density Inform Law Movement: Implications for Practice. Semin Ultrasound CT MR. 39(1):16-24, 2018
                                        5. van der Waal D et al: Breast density and breast cancer-specific survival by detection mode. BMC Cancer. 18(1):386, 2018
                                        6. DenseBreast-info.org: Legislation and Regulations. http://densebreast-info.org/legislation.aspx. Published 2015. Revised May 7, 2018. Accessed May 16, 2018
                                        7. Destounis S et al: Using volumetric breast density to quantify the potential masking risk of mammographic density. AJR Am J Roentgenol. 208(1):222-227, 2017
                                        8. Engmann NJ et al: Population-attributable risk proportion of clinical risk factors for breast cancer. JAMA Oncol. 3(9):1228-1236, 2017
                                        9. Engmann NJ et al: Longitudinal changes in volumetric breast density with tamoxifen and aromatase inhibitors. Cancer Epidemiol Biomarkers Prev. 26(6):930-937, 2017
                                        10. Ghosh K et al: Association between mammographic breast density and histologic features of benign breast disease. Breast Cancer Res. 19(1):134, 2017
                                        11. Irshad A et al: Changes in Breast Density Reporting Patterns of Radiologists After Publication of the 5th Edition BI-RADS Guidelines: A Single Institution Experience. AJR Am J Roentgenol. 209(4):943-948, 2017
                                        12. Lee CI et al: Risk-based breast cancer screening: Implications of breast density. Med Clin North Am. 101(4):725-741, 2017
                                        13. Wanders JOP et al: The effect of volumetric breast density on the risk of screen-detected and interval breast cancers: a cohort study. Breast Cancer Res. 19(1):67, 2017
                                        14. Wanders JO et al: Volumetric breast density affects performance of digital screening mammography. Breast Cancer Res Treat. 162(1):95-103, 2017
                                        15. Irshad A et al: Effects of Changes in BI-RADS Density Assessment Guidelines (Fourth Versus Fifth Edition) on Breast Density Assessment: Intra- and Interreader Agreements and Density Distribution. AJR Am J Roentgenol. 207(6):1366-1371, 2016
                                        16. Melnikow J et al: Supplemental Screening for Breast Cancer in Women With Dense Breasts: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 164(4):268-78, 2016
                                        17. Rafferty EA et al: Breast cancer screening using tomosynthesis and digital mammography in dense and nondense breasts. JAMA. 315(16):1784-6, 2016
                                        18. Sprague BL et al: Prevalence of mammographically dense breasts in the United States. J Natl Cancer Inst. 106(10), 2014
                                        19. Sickles EA et al: Breast Imaging Reporting and Data System, BI-RADS: Mammography. 5th ed. Reston: American College of Radiology, 2013
                                        20. Berg WA et al: Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 307(13):1394-404, 2012
                                        21. Bernardi D et al: Interobserver agreement in breast radiological density attribution according to BI-RADS quantitative classification. Radiol Med. 117(4):519-28, 2012
                                        22. Checka CM et al: The relationship of mammographic density and age: implications for breast cancer screening. AJR Am J Roentgenol. 198(3):W292-5, 2012
                                        23. Ghosh K et al: Tissue composition of mammographically dense and non-dense breast tissue. Breast Cancer Res Treat. 131(1):267-75, 2012
                                        24. Gierach GL et al: Relationship between mammographic density and breast cancer death in the Breast Cancer Surveillance Consortium. J Natl Cancer Inst. 104(16):1218-27, 2012
                                        25. Heine JJ et al: A novel automated mammographic density measure and breast cancer risk. J Natl Cancer Inst. 104(13):1028-37, 2012
                                        26. King V et al: Effect of aromatase inhibitors on background parenchymal enhancement and amount of fibroglandular tissue at breast MR imaging. Radiology. 264(3):670-8, 2012
                                        27. Razzaghi H et al: Mammographic density and breast cancer risk in White and African American Women. Breast Cancer Res Treat. 135(2):571-80, 2012
                                        28. Chan S et al: Menstrual cycle-related fluctuations in breast density measured by using three-dimensional MR imaging. Radiology. 261(3):744-51, 2011
                                        29. Cuzick J et al: Tamoxifen-induced reduction in mammographic density and breast cancer risk reduction: a nested case-control study. J Natl Cancer Inst. 103(9):744-52, 2011
                                        30. King V et al: Background parenchymal enhancement at breast MR imaging and breast cancer risk. Radiology. 260(1):50-60, 2011
                                        31. Lindström S et al: Common variants in ZNF365 are associated with both mammographic density and breast cancer risk. Nat Genet. 43(3):185-7, 2011
                                        32. Yaghjyan L et al: Mammographic breast density and subsequent risk of breast cancer in postmenopausal women according to tumor characteristics. J Natl Cancer Inst. 103(15):1179-89, 2011
                                        33. Arora N et al: Impact of breast density on the presenting features of malignancy. Ann Surg Oncol. 17 Suppl 3:211-8, 2010
                                        34. Chiu SY et al: Effect of baseline breast density on breast cancer incidence, stage, mortality, and screening parameters: 25-year follow-up of a Swedish mammographic screening. Cancer Epidemiol Biomarkers Prev. 19(5):1219-28, 2010
                                        35. Kerlikowske K et al: Breast cancer risk by breast density, menopause, and postmenopausal hormone therapy use. J Clin Oncol. 28(24):3830-7, 2010
                                        36. Pearman L et al: The effects of raloxifene on mammographic breast density: a review of clinical trials. Menopause. 17(3):654-9, 2010
                                        37. Cil T et al: Mammographic density and the risk of breast cancer recurrence after breast-conserving surgery. Cancer. 115(24):5780-7, 2009
                                        38. Harvey JA et al: Histologic changes in the breast with menopausal hormone therapy use: correlation with breast density, estrogen receptor, progesterone receptor, and proliferation indices. Menopause. 15(1):67-73, 2008
                                        39. Boyd NF et al: Mammographic density and the risk and detection of breast cancer. N Engl J Med. 356(3):227-36, 2007
                                        40. Kerlikowske K et al: Longitudinal measurement of clinical mammographic breast density to improve estimation of breast cancer risk. J Natl Cancer Inst. 99(5):386-95, 2007
                                        41. Porter GJ et al: Influence of mammographic parenchymal pattern in screening-detected and interval invasive breast cancers on pathologic features, mammographic features, and patient survival. AJR Am J Roentgenol. 188(3):676-83, 2007
                                        42. Hawes D et al: Dense breast stromal tissue shows greatly increased concentration of breast epithelium but no increase in its proliferative activity. Breast Cancer Res. 8(2):R24, 2006
                                        43. Martin KE et al: Mammographic density measured with quantitative computer-aided method: comparison with radiologists' estimates and BI-RADS categories. Radiology. 240(3):656-65, 2006
                                        44. McCormack VA et al: Breast density and parenchymal patterns as markers of breast cancer risk: a meta-analysis. Cancer Epidemiol Biomarkers Prev. 15(6):1159-69, 2006
                                        45. Li T et al: The association of measured breast tissue characteristics with mammographic density and other risk factors for breast cancer. Cancer Epidemiol Biomarkers Prev. 14(2):343-9, 2005
                                        46. Harvey JA et al: Quantitative assessment of mammographic breast density: relationship with breast cancer risk. Radiology. 230(1):29-41, 2004
                                        47. Guo YP et al: Growth factors and stromal matrix proteins associated with mammographic densities. Cancer Epidemiol Biomarkers Prev. 10(3):243-8, 2001
                                        48. Berg WA et al: Breast Imaging Reporting and Data System: inter- and intraobserver variability in feature analysis and final assessment. AJR Am J Roentgenol. 174(6):1769-77, 2000
                                        49. Porter PL et al: Breast tumor characteristics as predictors of mammographic detection: comparison of interval- and screen-detected cancers. J Natl Cancer Inst. 91(23):2020-8, 1999
                                        Related Anatomy
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                                        Related Differential Diagnoses
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                                        References
                                        Tables

                                        Tables

                                        KEY FACTS

                                        • Terminology

                                          • Imaging

                                            • Pathology

                                              • Clinical Issues

                                                TERMINOLOGY

                                                • Definitions

                                                  • BI-RADS defines 4 categories of breast density (A-D)
                                                    • Recommended but not required in mammogram report
                                                    • Density inform laws may require inclusion of breast density in lay mammogram results letters to patients (depending on state law)
                                                    • Category A: Almost entirely fatty
                                                    • Category B: Scattered areas of fibroglandular density
                                                      • Some cancers can be obscured even with only scattered density
                                                    • Category C: Heterogeneously dense, which may obscure small masses
                                                      • Some areas of parenchyma dense, others mostly fatty
                                                      • In dense areas, noncalcified masses can be masked
                                                      • Even if only 1 quadrant dense, categorize as heterogeneously dense
                                                    • Category D: Extremely dense, which lowers sensitivity of mammography
                                                      • Nearly entire breast shows dense tissue except for subcutaneous fat
                                                  • Dense breasts: Heterogeneously or extremely dense
                                                  • Nondense breasts: Fatty or scattered
                                                  • Subareolar density (due to normal ducts and ligaments) in isolation not usually included as "dense"
                                                  • Interval cancer: Detected clinically in interval between prescribed mammographic screens
                                                  • Fibroglandular tissue (FGT): Terminal duct lobular units (TDLUs), ducts, stroma, ligaments
                                                  • Quantitative software programs can measure percent mammographic density (PMD) in 2 dimensions (area) or 3 dimensions [volumetric breast density (VBD)]
                                                    • Even densest breast tissue only ~ 35% dense by volume when quantified

                                                IMAGING

                                                • General Features

                                                  • Mammographic Findings

                                                    • Ultrasonographic Findings

                                                      • MR Findings

                                                        • Imaging Recommendations

                                                          DIFFERENTIAL DIAGNOSIS

                                                            PATHOLOGY

                                                            • Microscopic Features

                                                              • Receptor Studies

                                                                CLINICAL ISSUES

                                                                • Presentation

                                                                  • Demographics

                                                                    • Natural History & Prognosis

                                                                      • Treatment

                                                                        DIAGNOSTIC CHECKLIST

                                                                        • Consider

                                                                          • Image Interpretation Pearls

                                                                            • Reporting Tips

                                                                              Selected References

                                                                              1. Brentnall AR et al: Long-term Accuracy of Breast Cancer Risk Assessment Combining Classic Risk Factors and Breast Density. JAMA Oncol. e180174, 2018
                                                                              2. Chowdhury M et al: Dose-dependent effect of mammographic breast density on the risk of contralateral breast cancer. Breast Cancer Res Treat. ePub, 2018
                                                                              3. Moshina N et al: Automated volumetric analysis of mammographic density in a screening setting: worse outcomes for women with dense breasts. Radiology. 288(2):343-352, 2018
                                                                              4. Raj SD et al: Deciphering the Breast Density Inform Law Movement: Implications for Practice. Semin Ultrasound CT MR. 39(1):16-24, 2018
                                                                              5. van der Waal D et al: Breast density and breast cancer-specific survival by detection mode. BMC Cancer. 18(1):386, 2018
                                                                              6. DenseBreast-info.org: Legislation and Regulations. http://densebreast-info.org/legislation.aspx. Published 2015. Revised May 7, 2018. Accessed May 16, 2018
                                                                              7. Destounis S et al: Using volumetric breast density to quantify the potential masking risk of mammographic density. AJR Am J Roentgenol. 208(1):222-227, 2017
                                                                              8. Engmann NJ et al: Population-attributable risk proportion of clinical risk factors for breast cancer. JAMA Oncol. 3(9):1228-1236, 2017
                                                                              9. Engmann NJ et al: Longitudinal changes in volumetric breast density with tamoxifen and aromatase inhibitors. Cancer Epidemiol Biomarkers Prev. 26(6):930-937, 2017
                                                                              10. Ghosh K et al: Association between mammographic breast density and histologic features of benign breast disease. Breast Cancer Res. 19(1):134, 2017
                                                                              11. Irshad A et al: Changes in Breast Density Reporting Patterns of Radiologists After Publication of the 5th Edition BI-RADS Guidelines: A Single Institution Experience. AJR Am J Roentgenol. 209(4):943-948, 2017
                                                                              12. Lee CI et al: Risk-based breast cancer screening: Implications of breast density. Med Clin North Am. 101(4):725-741, 2017
                                                                              13. Wanders JOP et al: The effect of volumetric breast density on the risk of screen-detected and interval breast cancers: a cohort study. Breast Cancer Res. 19(1):67, 2017
                                                                              14. Wanders JO et al: Volumetric breast density affects performance of digital screening mammography. Breast Cancer Res Treat. 162(1):95-103, 2017
                                                                              15. Irshad A et al: Effects of Changes in BI-RADS Density Assessment Guidelines (Fourth Versus Fifth Edition) on Breast Density Assessment: Intra- and Interreader Agreements and Density Distribution. AJR Am J Roentgenol. 207(6):1366-1371, 2016
                                                                              16. Melnikow J et al: Supplemental Screening for Breast Cancer in Women With Dense Breasts: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 164(4):268-78, 2016
                                                                              17. Rafferty EA et al: Breast cancer screening using tomosynthesis and digital mammography in dense and nondense breasts. JAMA. 315(16):1784-6, 2016
                                                                              18. Sprague BL et al: Prevalence of mammographically dense breasts in the United States. J Natl Cancer Inst. 106(10), 2014
                                                                              19. Sickles EA et al: Breast Imaging Reporting and Data System, BI-RADS: Mammography. 5th ed. Reston: American College of Radiology, 2013
                                                                              20. Berg WA et al: Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 307(13):1394-404, 2012
                                                                              21. Bernardi D et al: Interobserver agreement in breast radiological density attribution according to BI-RADS quantitative classification. Radiol Med. 117(4):519-28, 2012
                                                                              22. Checka CM et al: The relationship of mammographic density and age: implications for breast cancer screening. AJR Am J Roentgenol. 198(3):W292-5, 2012
                                                                              23. Ghosh K et al: Tissue composition of mammographically dense and non-dense breast tissue. Breast Cancer Res Treat. 131(1):267-75, 2012
                                                                              24. Gierach GL et al: Relationship between mammographic density and breast cancer death in the Breast Cancer Surveillance Consortium. J Natl Cancer Inst. 104(16):1218-27, 2012
                                                                              25. Heine JJ et al: A novel automated mammographic density measure and breast cancer risk. J Natl Cancer Inst. 104(13):1028-37, 2012
                                                                              26. King V et al: Effect of aromatase inhibitors on background parenchymal enhancement and amount of fibroglandular tissue at breast MR imaging. Radiology. 264(3):670-8, 2012
                                                                              27. Razzaghi H et al: Mammographic density and breast cancer risk in White and African American Women. Breast Cancer Res Treat. 135(2):571-80, 2012
                                                                              28. Chan S et al: Menstrual cycle-related fluctuations in breast density measured by using three-dimensional MR imaging. Radiology. 261(3):744-51, 2011
                                                                              29. Cuzick J et al: Tamoxifen-induced reduction in mammographic density and breast cancer risk reduction: a nested case-control study. J Natl Cancer Inst. 103(9):744-52, 2011
                                                                              30. King V et al: Background parenchymal enhancement at breast MR imaging and breast cancer risk. Radiology. 260(1):50-60, 2011
                                                                              31. Lindström S et al: Common variants in ZNF365 are associated with both mammographic density and breast cancer risk. Nat Genet. 43(3):185-7, 2011
                                                                              32. Yaghjyan L et al: Mammographic breast density and subsequent risk of breast cancer in postmenopausal women according to tumor characteristics. J Natl Cancer Inst. 103(15):1179-89, 2011
                                                                              33. Arora N et al: Impact of breast density on the presenting features of malignancy. Ann Surg Oncol. 17 Suppl 3:211-8, 2010
                                                                              34. Chiu SY et al: Effect of baseline breast density on breast cancer incidence, stage, mortality, and screening parameters: 25-year follow-up of a Swedish mammographic screening. Cancer Epidemiol Biomarkers Prev. 19(5):1219-28, 2010
                                                                              35. Kerlikowske K et al: Breast cancer risk by breast density, menopause, and postmenopausal hormone therapy use. J Clin Oncol. 28(24):3830-7, 2010
                                                                              36. Pearman L et al: The effects of raloxifene on mammographic breast density: a review of clinical trials. Menopause. 17(3):654-9, 2010
                                                                              37. Cil T et al: Mammographic density and the risk of breast cancer recurrence after breast-conserving surgery. Cancer. 115(24):5780-7, 2009
                                                                              38. Harvey JA et al: Histologic changes in the breast with menopausal hormone therapy use: correlation with breast density, estrogen receptor, progesterone receptor, and proliferation indices. Menopause. 15(1):67-73, 2008
                                                                              39. Boyd NF et al: Mammographic density and the risk and detection of breast cancer. N Engl J Med. 356(3):227-36, 2007
                                                                              40. Kerlikowske K et al: Longitudinal measurement of clinical mammographic breast density to improve estimation of breast cancer risk. J Natl Cancer Inst. 99(5):386-95, 2007
                                                                              41. Porter GJ et al: Influence of mammographic parenchymal pattern in screening-detected and interval invasive breast cancers on pathologic features, mammographic features, and patient survival. AJR Am J Roentgenol. 188(3):676-83, 2007
                                                                              42. Hawes D et al: Dense breast stromal tissue shows greatly increased concentration of breast epithelium but no increase in its proliferative activity. Breast Cancer Res. 8(2):R24, 2006
                                                                              43. Martin KE et al: Mammographic density measured with quantitative computer-aided method: comparison with radiologists' estimates and BI-RADS categories. Radiology. 240(3):656-65, 2006
                                                                              44. McCormack VA et al: Breast density and parenchymal patterns as markers of breast cancer risk: a meta-analysis. Cancer Epidemiol Biomarkers Prev. 15(6):1159-69, 2006
                                                                              45. Li T et al: The association of measured breast tissue characteristics with mammographic density and other risk factors for breast cancer. Cancer Epidemiol Biomarkers Prev. 14(2):343-9, 2005
                                                                              46. Harvey JA et al: Quantitative assessment of mammographic breast density: relationship with breast cancer risk. Radiology. 230(1):29-41, 2004
                                                                              47. Guo YP et al: Growth factors and stromal matrix proteins associated with mammographic densities. Cancer Epidemiol Biomarkers Prev. 10(3):243-8, 2001
                                                                              48. Berg WA et al: Breast Imaging Reporting and Data System: inter- and intraobserver variability in feature analysis and final assessment. AJR Am J Roentgenol. 174(6):1769-77, 2000
                                                                              49. Porter PL et al: Breast tumor characteristics as predictors of mammographic detection: comparison of interval- and screen-detected cancers. J Natl Cancer Inst. 91(23):2020-8, 1999