Triangulation of Breast Lesions: Review
and Clinical Applications
Jeong Mi Park, MD, and Edmund A. Franken, Jr., MD
Although the concept of triangulation of breast lesions has
been well-defined in the literature, it is still frequently
misunderstood or applied incorrectly. We provide a review
of the basic concept, discuss common misapplications of
triangulation and the reasons they happen, and demon-
strate typical and exceptional cases, as well as mammog-
raphy– ultrasound correlations using diagrams and illustra-
tive cases.
Although mammography has been the primary imag-
ing modality of breast lesions, other modalities such as
ultrasound and magnetic resonance imaging are fre-
quently necessary to further evaluate abnormalities
seen on a mammography due to the limited ability of
mammography to differentiate benign and malignant
lesions. Because of the relative lack of anatomic
landmarks in the breast, correlation of the location of
the lesions frequently is the primary problem before
performing further characterization of the lesions.
Errors in correlation of location can make differences
between correct timely diagnosis and nondiagnosis or
false diagnosis or delayed diagnosis. Nevertheless, the
basic concepts of triangulation of breast lesions are
quite geometric and application should be almost
automatic once the concept is well understood.1-6 We
discuss demonstrable cases of triangulation as well as
the basic concept and variations. The mammography–
ultrasound correlation is also provided, considering
increasing use of ultrasound to evaluate breast lesions.
From the Division of Breast Imaging and Intervention, Department of
Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA.
Reprint requests: Jeong Mi Park, MD, Division of Breast Imaging and
Intervention, Department of Radiology, The University of Iowa Hospitals
and Clinics, 200 Hawkins Drive, 3961 JPP, Iowa City, IA 52242-1082.
E-mail: jeongmi-park@uiowa.edu.
Curr Probl Diagn Radiol 2008;37:1-14.
© 2008 Mosby, Inc. All rights reserved.
0363-0188/2008/$34.00 ⫹ 0
doi:10.1067/j.cpradiol.2007.09.001
Curr Probl Diagn Radiol, January/February 2008
The Most Common Misapplication
Many of us tend to trust the location of a lesion as it
is seen on a mediolateral oblique (MLO) view. In
truth, the apparent location of a lesion on an MLO
view is not defined unless the MLO view is combined
with at least one other view.
The three MLO views demonstrated in Figs 1-3 all
show lesions at the nipple level, suggesting the loca-
tion to be at either 3 o’clock or 9 o’clock, but the
actual locations are different. Each diagram demon-
strates the reason for the difference. We think that this
misapplication happens most frequently. Whenever
there is a lesion seen at the nipple level on MLO view,
further evaluation about the true location must be
performed before it is called either a 3 o’clock lesion
or a 9 o’clock lesion.
A similar mistake occurs when we see lesions
above or below the nipple level on MLO views. What
seems to be above the nipple on an MLO view can
actually be located below the nipple and vice versa, as
will be discussed later.
The Second Most Common Misapplication
We tend to regard a lesion seen posteriorly high near
the pectoralis muscle on MLO view as one located in
the upper outer quadrant, near the axilla.
In truth, these lesions can be located in the upper
outer quadrant, near the axilla, but they also can be
located in the upper inner quadrant, which is the
opposite side to the axilla (Figs 4-6).
Review of the Basic Concept
of Triangulation
To understand the basic concept of triangulation, we
can start with the following assumptions:
1. The breast is considered a perfect half-sphere with
even compressibility in all four quadrants.
1
 Right Breast Left Breast
Superior

Lateral Medial
Inferior

Nipple Level

D CC View MLO View ML View

FIG 1. A benign calcification in right upper inner quadrant. The calcification is seen at the nipple level on MLO view (B), misdirecting us to think
the location is at either the 3 o’clock or the 9 o’clock position. However, because the calcification is located in the medial right breast on
craniocaudal (CC) view (A), it should be located in the upper right breast from triangulation and 90-degree mediolateral (ML) view confirms the
location (C). Therefore, this calcification is located in the upper inner quadrant of the right breast. (D) This diagram shows how a lesion in upper
inner right breast is projected on each view and is aligned on a straight line when all three views are arranged in the order of CC-MLO-ML views.
The x-ray beam (green arrow for a lesion, red arrow for the nipple) through the breast and the lesion (circles) is always vertical to the detector (thin
rectangle) in standard CC, MLO, and ML views. (Color version of figure is available online.)

2. There is no divergence in the x-ray beam.
3. The MLO view is performed at a 45-degree angle.
Then the concepts can be understood very geometri-
cally. The x-ray beam and the detector always move
together like the “x-ray-breast-detector (image)” axis
is a straight line which can rotate virtually 360 degrees
freely. Therefore, when we connect the lesion location
on each standard image in the order of CC-MLO-ML
view or ML-MLO-CC view with the nipple at the
same level, the line connecting the lesions should be
straight, with the lesion location on MLO view located
at the pivot point of the line. Therefore, if a lesion

2 Curr Probl Diagn Radiol, January/February 2008

 A B

Right Breast Left Breast

Superior

Lateral Medial
Inferior

Nipple Level

D CC View MLO View ML View

FIG 2. Right central lesion. Stable benign-appearing mass. The central posterior mass is seen at the nipple level on MLO view (B), misdirecting
us to think the location could be at either the 3 o’clock or the 9 o’clock position. However, because the mass is located in the central right breast
on CC view (A), it should be located in central right breast on 90-degree ML view (not taken) and the true location is in the central posterior right
breast as seen on the ultrasound (C). (D) This diagram shows how a centrally located lesion is projected on each view and is aligned on a straight
line when all three views are arranged in the order of CC-MLO-ML views (pink line). (Color version of figure is available online.)

appears to be located in the center of the breast on an
MLO view, it can be located virtually anywhere in the
breast (Fig 7). To extend this concept to more com-
plicated cases, as stated before, the location of a lesion
on MLO view functions similar to a pivot point
between those of CC and ML views. However, the line
connecting the lesions on each view does not have to
traverse the central portion of the MLO view (Figs
8-10). Essentially, the lines can be anywhere with
variable angles (Fig 11). This is why the MLO view
does not tell us the actual location of the lesion. For
example, what seems to be above the nipple on MLO
view can actually be located below the nipple and
what seems to be below the nipple on MLO view can
actually be located above the nipple (Figs 12 and 13).
It is very important to remember that the apparent
location of a lesion seen on MLO view frequently
misdirects us about the true location of the lesion.
Therefore, we should be very careful in determining
the true location of lesions seen on MLO view until it
is combined with at least one other view.
Practical Tips to Apply Triangulation
Here we describe how we actually apply the above
described concepts to our daily practice. We would
like to suggest the two following methods.
Method I (Line Method)
This method was used for the previously shown
diagrams.

Curr Probl Diagn Radiol, January/February 2008 3

 Right Breast Left Breast
Superior

Medial Lateral Inferior

Nipple Level

D CC View MLO View ML View

FIG 3. Left lower outer quadrant lesion. Adenoid cystic carcinoma. The ill-defined mass is seen at the nipple level on MLO view (B), misdirecting
us to think the location is at either the 3 o’clock or the 9 o’clock position. Initial ultrasound targeting of the 9 o’clock area did not find the mass.
Because the mass is located in the lateral left breast on CC view (A), it should be located in the lower right breast on 90-degree ML view (not taken)
and the true location is in the lower outer quadrant at 4 o’clock, as seen on a second look ultrasound (C, marked). (D) This diagram shows how
a left lower outer breast lesion is projected on each view and is aligned on a straight line when all three views are arranged in the order of
CC-MLO-ML views. (Color version of figure is available online.)

1. Put any two views from CC, MLO, or ML with the
nipple at the same level on all images. These two
views may or may not include MLO view. (If there
are all three views available, put all three views
with the nipple at the same level.)
2. Draw a straight line through the lesions on the two
(or three) views, assuming the MLO view is in the
center of all three views.
3. Determine the location of the lesion on the third
view (or simply confirm that the line is straight
through all three views).
Note that, at the start, we assumed that the MLO view
was performed at a 45-degree angle. If it is performed
at other than a 45-degree angle, the location of lesions
seen on the MLO view moves toward the locations

4 Curr Probl Diagn Radiol, January/February 2008

FIG 4. An example of an upper outer quadrant lesion. Papillary carcinoma. The lesion is seen above the nipple on the MLO view (B) and is also
seen higher than the nipple on the CC view, meaning the lateral location (A), and is therefore located in the left upper outer quadrant at 1 o’clock,
as confirmed on a following ultrasound (C). (Color version of figure is available online.)

seen either on the CC view or on the ML view,
according to the particular angles. Therefore, it is
important to consider the actual angle of the MLO
view in determining the true location of the lesions
(Figs 14 and 15).
Method II (Moving Distance Method)
Method II does not use an actual line and is more
convenient once we get familiar with it.
1. Put any two views from CC, MLO, or ML views
with the nipple at the same level on all images.
These two views may or may not include MLO
view. (If all three views are available, put all three
views with the nipple at the same level.)
2. Note the distance of the lesion from the nipple on
each view and observe the direction and the
amount of change (movement) from one view to
the other view, assuming the MLO view is in the
center of the all three views. The direction and
amount of movement should be following the
same straight line as would be determined from the
Line Method.
3. Determine the location of the lesion on the third
view (or simply confirm that the direction and the
amount of movement is following the same
straight line through all three views as would be
determined from the Line Method) (Fig 16).
Note that this moving distance method applies better
from a practical standpoint because it is difficult to put
all two/three images with the nipple at the same level on
the viewer and draw a traversing straight line through
those images (Fig 17). The moving distance method can
be done mentally, and images do not have to be physi-
cally rearranged. We can also understand that more
centrally located lesions remain near the nipple on all
three views during this “movement,” and more periph-
erally located lesions move farther distance from the
nipple (Figs 18 and 19).
Why Are There Exceptions?
We would like to believe that the basic concept of
triangulation works well in all cases; however, we

Curr Probl Diagn Radiol, January/February 2008 5

FIG 5. Invasive ductal carcinoma and ductal carcinoma in situ (DCIS). The lesion is not seen on the CC view (A) but is seen above the nipple
posteriorly near pectoralis muscle on MLO view (B), which can frequently be misinterpreted as an upper outer quadrant lesion. Initial ultrasound
targeting of upper outer quadrant did not find any mass. On further triangulation, this mass is seen higher up posteriorly on 90-degree ML view
(C), and therefore, it must be located in the medial breast. Targeted ultrasound of the right upper inner quadrant shows the ill-defined hypoechoic
mass with thick boundary echogenicity, suggestive of malignancy (D). (Color version of figure is available online.)

frequently encounter exceptions. Review of the previ-
ously mentioned basic assumptions of triangulation
explains why we may see variability in our results:
1. Assumption: The breast is considered as a perfect
half-sphere with even compressibility in all four
quadrants. Reality: The breasts are not perfect
half-spheres, and the compressibility is different in
different quadrants.
2. Assumption: There is no divergence in the x-ray
beam. Reality: Peripherally located lesions in a
large breast can be affected by the divergence,
even though this effect may be negligible.

6 Curr Probl Diagn Radiol, January/February 2008

FIG 6. Postsurgical changes in left upper inner quadrant. Ill-defined postsurgical changes are seen above the nipple posteriorly near the pectoralis
muscle on the MLO view (B), making it easy to be misinterpreted as an upper outer quadrant location. However, the asymmetry is seen in the medial
left breast on CC view (A); therefore, the true location is in the upper inner quadrant. Targeted ultrasound of left upper inner quadrant shows the
ill-defined postsurgical changes (C). (Color version of figure is available online.)

Right Breast Left Breast

Superior

Lateral Medial
Inferior

FIG 7. If a lesion appears to be located in the center of the breast on

an MLO view, it can be located virtually anywhere in the breast (blue,
purple, red lines). (Color version of figure is available online.) Nipple Level

CC View MLO View ML View

FIG 9. A diagram showing a right upper outer quadrant lesion. When

we connect the locations of the lesion on CC, MLO, and ML views, the
connecting line is straight and remains in the upper lateral portion of
the right breast as seen here. An example of left upper outer quadrant
lesion is demonstrated in Fig 4. (Color version of figure is available
online.)

FIG 8. The line connecting lesions on each view does not have to 3. Assumption: The MLO view is performed at a
traverse the central portion of the MLO view (blue, purple, red lines).
Examples are shown in Figs 9 and 10. (Color version of figure is 45-degree angle. Reality: The actual angle can
available online.) vary according to each patient’s body habitus. The

Curr Probl Diagn Radiol, January/February 2008 7

 Right Breast Superior
Left Breast

Lateral Medial
Inferior

Nipple Level

CC View MLO View ML View

FIG 12. A lesion located slightly above the nipple near 2:30 o’clock
in the right breast. Although the lesion seems to be below the nipple on
the MLO view, the lesion is actually located above the nipple. (Color
version of figure is available online.)

Right Breast Left Breast

Superior

Lateral Medial
Inferior

Right Breast Left Breast

Superior

Nipple Level

Lateral Medial
Inferior

CC View MLO View ML View

FIG 13. A lesion located slightly below the nipple near 8:30 o’clock
in the right breast. Although the lesion seems to be above the nipple on
Nipple Level
the MLO view, the lesion is actually located below the nipple. (Color
version of figure is available online.)

C CC View MLO View ML View

FIG 10. (A and B) The same principle applies to lower inner quadrant
lesions. Here a lesion is located in the lower inner quadrant of the right
breast. (C) When we connect the locations of the lesion on these three
views, the connecting line is straight and remains in the lower medial
portion of the right breast. (Color version of figure is available online.)
positioning technique can differ by technologists
and/or examinations.
Think about the principle first. If it does not work, be
flexible with the above assumptions. The flexibility
has to be within an acceptable range; for example,
significant bending of the line should not normally
occur (Fig 20).

FIG 11. The connecting lines can be anywhere with variable direc-
tions (blue and red lines). (Color version of figure is available online.)
Mammography–Ultrasound Correlation
The use of ultrasound in breast imaging has become
more and more important for both lesion characteriza-
tion and invasive procedures. However, correct corre-
lation between mammography and ultrasound is es-

8 Curr Probl Diagn Radiol, January/February 2008

 Right Breast Left Breast Right Breast Left Breast
Superior Superior

Lateral Medial Inferior Inferior Medial Lateral

Nipple
Level
Nipple Level

CC View MLO View ML View

ML View MLO View CC View

FIG 16. Left breast lesion at 3 o’clock. The lesion is seen at the nipple
Nipple
Level level on the ML view. Note how the lesion “moves up” from the ML view
to the CC view (green arrows), following the line as would be determined
from the Line Method (red line). (Color version of figure is available
CC View MLO View ML View online.)
FIG 14. A case in which the angle of the MLO view is larger than 45 Right Breast Left Breast
Superior
degrees. The location of the lesion on the MO view is closer to the
location on the ML view. If this factor is not considered and the location
on MLO view is interpreted as if the MLO view is done with 45
degrees, then the estimated final location of the lesion on ML view
would be higher than the actual location (green arrowed line). (Color
version of figure is available online.) Lateral Medial
Inferior

Nipple Level

Right Breast Superior

Left Breast
CC View MLO View ML View

FIG 17. Modified diagram of Fig 1D. In practice, the MLO and ML
views need to be rearranged as shown in this diagram to match the
real direction of the underlying breast tissue on each view. The degree
Lateral Medial Inferior
of adjustment can be varied from patient to patient. (Color version of
figure is available online.)

Nipple Right Breast Left Breast

Superior
Level

CC View MLO View ML View

Medial Lateral Inferior

Nipple
Level

CC View MLO View ML View Nipple Level

FIG 15. A case in which the angle of the MLO view is smaller than 45
degrees. The location of the lesion on the MLO view is closer to the
location on CC view. If this factor is not considered and the location on
MLO view is interpreted as if the MLO view is done at 45 degrees, the CC View MLO View ML View

estimated final location of the lesion on the ML view would be lower FIG 18. If a lesion is located near the nipple, the moving distance of
than the actual location (green arrowed line). (Color version of figure the lesion through different views would be small and would remain
is available online.) near the nipple. (Color version of figure is available online.)

Curr Probl Diagn Radiol, January/February 2008 9

 Right Breast Left Breast
Superior
Medial Lateral Inferior
Nipple Level
CC View MLO View ML View
FIG 19. If a lesion is located more peripherally, the moving distance
of the lesion through different views would be larger and farther from
the nipple. (Color version of figure is available online.)
Nipple Level
CC View MLO View ML View
FIG 20. The line connecting each location of a lesion on three views
should not bend like this red line. If the location of the lesion on CC and
MLO views is correct, the lesion should be located in the lower outer
quadrant; therefore, it cannot be projected in the upper breast on the
ML view. If the location of the lesion on the MLO and ML views is
correct, the lesion should be located in the upper inner quadrant;
therefore, it cannot be projected in the lateral breast on CC view.
(Color version of figure is available online.)
FIG 21. Comparison of the right CC view (A) and transverse image of
the right breast ultrasound (B). Right breast lateral lesion (green circle)
has to be in the midportion of the parenchymal depth, while the red
one is close to the nipple anteriorly, in the subareolar area, and the
yellow one is immediately in front of the retroglandular fat, centrally
and posteriorly. (Color version of figure is available online.)
10
FIG 22. Comparison of the right CC view (A) and transverse image of
the right breast ultrasound (B). The pink lesion has to be very anteriorly
located, protruding into the subcutaneous fat, while the red lesion is
centrally posteriorly located within the retroglandular fat. In this case,
not only is the pink lesion farther from the nipple than the red lesion, but
it is also more shallowly located under the skin than the red lesion.
Likewise, if you see any lesion in the mid-depth of the parenchyma on
ultrasound (green circle), that is neither the pink lesion nor the red
lesion, even though it is in the same quadrant and at a similar distance
from the nipple as the pink lesion, it is likely the third lesion, which is
probably not well visualized on the mammogram. Also, both pink and
red lesions seem to be the same distance from the nipple on mammog-
raphy (black arrows). However, the pink lesion is away from the nipple
on both mammography and ultrasonography at similar distances,
while the red lesion is closer to the nipple in the central posterior
portion of the breast on ultrasound (red arrow), which is different from
findings on mammography. Therefore, the distance from the nipple
that we should use for mammography– ultrasound correlation is the red
and blue lines, not the black lines. (Color version of figure is available
online.)
sential in both lesion characteristics and intervention.
If this correlation is performed incorrectly, then we
may either miss the correct lesion (false negative) or
perform biopsy in the wrong area. The advanced
current technology of ultrasound has made it possible
to identify even 2 or 3 millimeter lesions; therefore,
correct mammography– ultrasound correlation must be
confirmed if there is apparent negative ultrasound results
for obvious mammography findings (Figs 3 and 5).
Again, correlation of the location of the lesions fre-
quently is the primary problem before performing
further characterization of the lesions.
One important difference to remember between
these two modalities is that we stretch the breast tissue
maximally for mammography and see the breast either
from above or from the side with different angles. By
contrast, on ultrasound the breast tissue is lying flat
without any tension or compression, and we see the
breast tissue from anterior to posterior. These differ-
Curr Probl Diagn Radiol, January/February 2008
FIG 23. Invasive lobular carcinoma in the left breast. Mammography– ultrasound correlation. An irregularly shaped mass in the central left breast
on CC and MLO mammogram (A and B) is further evaluated with ultrasound. A cyst is found near the nipple, but it does not correspond to the mass
because it is located too shallowly immediately below the subcutaneous fat (C). The mass is located deep in the central breast tissue (D). (Color
version of figure is available online.)

ences explain why we need to correlate the findings on
each examination carefully.
There are three essential mammography– ultrasound
correlations regarding location of a lesion: correlation of
quadrants, correlation of depth, and correlation of dis-
tance from the nipple. Correlation of quadrants should
not be a problem if the triangulation from mammography
is done correctly. Correlation of depth in the breast
parenchyma and correlation of distance from the nipple
often need additional evaluation (Figs 21-24).
Correlation of depth must be carefully considered
especially in shallow lesions. We have discussed the
problems of MLO views; however, problems can occur
with CC and ML views, too, regarding depth. The lesions
that seem to be located very deep posteriorly on one view
can be truly located far peripherally and shallowly
beneath the skin on the other view. This is especially
important for image-guided invasive procedures such as
needle-wire localization or ultrasound-guided core bi-
opsy or stereotactic core biopsy. Because a 90-degree
ML view is not routinely performed initially, it is
important to remember that the actual depth of a lesion
from the skin surface can be quite different from the
apparent depth of a lesion as measured from CC or MLO
views (Figs 25 and 26).
Finally, we would like to mention that all diagrams
except Fig 17 are extremely simplified to make the
drawings geometrically easy to understand. The MLO
and ML views on a connecting line are all arranged
straight without slant in diagrams, while in actual prac-
tice, the mammograms need to be variably slanted. In
practice, this adjustment has to be done according to the
real direction of the breast tissue to be arranged with the
same nipple level (Fig 17).

Curr Probl Diagn Radiol, January/February 2008 11

FIG 24. DCIS. Mammography– ultrasound correlation. A small developing mass was seen on a routine screening CC and MLO mammogram
(A, B, red circle). According to the triangulation, this mass is located in the anterior lower outer quadrant near the nipple. Following ultrasound,
a similar size hypoechoic lesion was found in the anterior lower outer quadrant (C). Ultrasound-guided core biopsy was performed with no
significant pathologic abnormality. However, on the postbiopsy CC and MLO mammograms, the clip is located in the 9 o’clock area and apart
from the nipple. The mass is still identified (D and E, red circle). Repeat ultrasound found another similar size hypoechoic mass with a
microlobulated border in the anterior lower outer quadrant near the nipple (F). Second ultrasound-guided core biopsy was performed that gave
a diagnosis of DCIS. (G and H) The second postbiopsy CC and MLO mammograms show a second clip located in the correct area with no residual
mass. Regarding mammography– ultrasound correlation, triangulation of quadrant was correct in this case; however, correlation of distance from
the nipple was initially incorrect and caused misdiagnosis. (Color version of figure is available online.)

12 Curr Probl Diagn Radiol, January/February 2008

FIG 25. Ruptured epidermal inclusion cyst in the left breast. Mammography– ultrasound correlation of the depth. The mass is identified at the nipple
level and posteriorly on MLO view (B). However, the mass is shallowly located in the medial left breast on CC view (A), making the true location
the upper inner quadrant as confirmed by ultrasound (C). Note that the mass is not located in either 9 o’clock area or deeply posteriorly in the
breast. (Color version of figure is available online.)

A CC View
ML View
B ML View CC View

FIG 26. (A and B) These diagrams illustrate why we can be wrong in identifying locations of lesions even on CC and ML views. Lesions can be
projected at the same location on one view, even though they are actually at different locations. The blue lesions are shallowly located immediately
under the skin but from the other view, it looks like they are located far deeply posteriorly. However, we can at least narrow down the possible
locations of a lesion from the CC view or from the ML view, which are somewhere between either 12 o’clock and 6 o’clock (A) or somewhere at
the nipple level (B). (Color version of figure is available online.)

In summary, we may consider these statements as
convenient reminders:
1. The apparent location of a lesion seen on an MLO
view can be frequently incorrect unless it is com-
bined with at least one other view.
2. The lesions that are located either far superolaterally
or far inferomedially remain at the same distance
from the nipple superiorly or inferiorly on all three
views.
3. A central lesion remains in the central location on
all three views.
4. The relatively centrally located lesions remain
near the nipple on all three views.
5. The more peripherally located lesions tend to
move farther from the nipple from one view to
another.
6. We can guess the true location of a lesion from
only two views and those two views need not
necessarily include the MLO view.

Curr Probl Diagn Radiol, January/February 2008 13

7. Mammography– ultrasound correlations regarding
location of a lesion should include correlation of
quadrants, correlation of depth, and correlation of
distance from the nipple.
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Curr Probl Diagn Radiol, January/February 2008