Atlas of Mammography

Chapter 8

Asymmetry and Architectural Distortion

Asymmetry of the parenchyma is a common finding on mammography, and it is observed when the same mammographic views are visualized together as mirror images. The observation of asymmetry may be related to a greater degree of parenchyma in one breast, loss of parenchyma through surgery, superimposition of parenchyma, or a true lesion that may be benign or malignant. In the current Breast Imaging Reporting and Data System (BI-RADS®) lexicon (1), three terms are used to describe nonmass densities: focal asymmetry, global asymmetry, and architectural distortion. A previously used term for a potential abnormality on a screening study was a density on one view. In this chapter, the etiologies and management of these findings will be described.

A Density Seen on One View

Overlying glandular tissue can be visualized on one projection as a focal density, but on the orthogonal view, it is seen to disperse. Such density may be a pseudolesion that is related to superimposition of the parenchyma, creating the appearance of an asymmetry or mass on one view. A density seen on one view also may be caused by a true lesion that is obscured by dense parenchyma on the other view (Fig. 8.1). In many cases, a single additional image provides sufficient information to differentiate overlapping tissue from a true lesion (2,3,4,5). Spot compression views of the area may be of help in its evaluation and in displacing the surrounding glandular tissue. In addition, off-angle views such as rolled craniocaudal (CC), 90-degree lateral, or step-obliques are used to confirm that a density is a real finding and to verify its location.

The step-oblique mammography technique is used to determine with confidence whether a mammographic finding visible on one projection only represents a summation artifact or if it is a true mass. Pearson et al. (6) described this technique, in which serial images are obtained at 15-degree intervals from the view on which the finding is seen, moving toward the view in which it is not seen. Based on the persistence of the finding or its disappearance on the additional views, the nature of the density can be elucidated (6).

Asymmetry

The BI-RADS® lexicon (1) describes a global asymmetry as asymmetric breast tissue or a greater volume of breast tissue in comparison with the corresponding region of the opposite breast. Global asymmetry is usually a normal variant, but when it is palpable or associated with other suspicious findings, it may be significant. For global asymmetry to be considered benign based on mammography, it should not be associated with a mass, architectural distortion, or suspicious microcalcifications. Global asymmetry may be related to a greater volume of parenchyma in one breast, a hypoplastic breast, or the removal of parenchyma in one breast (Figs. 8.2,Figs. 8.3,8.4).

Asymmetric breast tissue has been reported to occur on 3% of mammograms and is most often benign (7). However, asymmetric breast tissue that is new, enlarging, or more dense than on prior mammograms may prompt further evaluation. Piccoli et al. (8) found that a common histopathologic finding in cases of developing asymmetric breast tissue that was biopsied was pseudoangiomatous stromal hyperplasia (PASH). In 13 biopsied cases of an enlarging asymmetry, the authors (8) found that PASH was extensive in 12 cases, and in 9%, it was the predominant feature.

A focal asymmetry, also sometimes called an asymmetric density, refers to an area of tissue that is visible on two views. A focal asymmetry has a similar shape on two views, but it does not have the conspicuity or the borders of a mass (1). A focal asymmetry can represent an island of normal breast tissue, or it can be caused by a variety of benign and malignant conditions. A focal asymmetry that is new or enlarging, palpable,

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associated with suspicious microcalcifications or architectural distortion, or that is evident on ultrasound as a solid mass necessitates further evaluation with biopsy. The types of focal asymmetries that may require biopsy are shown in Table 8.1.

TABLE 8.1 Suspicious Asymmetries

·   New or enlarging from prior mammography

·   Palpable

·   Associated with architectural distortion

·   Associated with suspicious microcalcifications

·   Associated with skin or nipple retraction

·   A solid mass on ultrasound

 

Figure 8.1 HISTORY: A 35-year-old woman for baseline mammogram.

MAMMOGRAPHY: Left MLO (A) and CC (B) views show a focal density in the superior aspect of the breast seen only on the MLO view(arrow). The finding is not seen on a similar configuration on the CC view and therefore represents superimposition of parenchyma. An ML view (C) confirms that the density does not remain in a similar configuration.

IMPRESSION: Pseudolesion: superimposition of tissue creating a focal density.

The mammographic evaluation of a focal asymmetry is to determine if it has a similar appearance on two views, where it is located, and if it has associated findings (Figs. 8.5 and 8.6). If the asymmetry is most evident on the CC view, rolled lateral and medial CC views are most helpful in addition to the spot compression to determine whether a focal asymmetry is real or not. In addition, the rolled view helps to establish the location of an asymmetry (9). Spot compression magnification helps to identify suspicious microcalcifications associated with the asymmetry as well as the margins of the abnormality.

In addition to the diagnostic mammographic evaluation of a focal asymmetry, ultrasound is also important. Sonography may reveal a solid or cystic mass that accounts for the asymmetric density. The presence of a solid mass that is associated with a focal asymmetry

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should be viewed with suspicion. A negative ultrasound may also be helpful to confirm that a focal asymmetry thought to be breast tissue on mammography is benign.

 

Figure 8.2 HISTORY: A 41-year-old woman for baseline screening mammography.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show an asymmetric appearance of the breasts. There is generally more volume of breast parenchyma on the right, located superiorly and laterally.

IMPRESSION: Global asymmetry, a normal variant.

 

Figure 8.3 HISTORY: A 37-year-old woman for baseline screening mammography.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show a greater region of parenchyma in the right upper-outer quadrant in comparison with the left breast. There are no suspicious associated findings.

IMPRESSION: Global asymmetry, right breast.

 

Figure 8.4 HISTORY: A 38-year-old woman for a baseline mammogram.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show an asymmetric appearance of the breasts. There is generalized increased parenchymal density in the right breast, consistent with global asymmetry.

IMPRESSION: Global asymmetry, a normal variant.

The etiologies of focal asymmetries range from normal glandular tissue to benign and malignant entities (Table 8.2). Normal fibroglandular tissue may be the cause of a focal asymmetry on mammography. Normal fibroglandular tissue should not be palpable or associated with distortion or microcalcifications (Table 8.3). Such asymmetries are sensitive to hormonal stimulation and may occur in women on oral contraceptives or on hormone replacement therapy (10). Because of this, a follow-up mammogram in 3 to 4 weeks after discontinuation of hormones may be performed for a questionable asymmetry. Normal fibroglandular tissue usually regresses and may be followed with mammography rather than evaluated further. A persistent new focal asymmetry that developed when the patient was placed on hormones, but that does not diminish with discontinuation of hormonal therapy, should be biopsied.

TABLE 8.2 Etiologies of a Focal Asymmetry

·   Normal fibroglandular tissue

·   Ectopic breast tissue

·   Focal fibrocystic change

·   Hematoma

·   Diabetic fibrous mastopathy

·   Pseudoangiomatous stromal hyperplasia

·   Carcinoma (invasive lobular, invasive ductal)

·   Lymphoma

Benign Causes of Asymmetry

Benign etiologies of focal asymmetries are the same as the causes of indistinct masses. Fibrocystic changes (Figs. 8.7 and 8.8), particularly focal fibrosis, and sclerosing adenosis often appear as a focal asymmetry. Sclerosing adenosis is a proliferation of ductules and lobular glands (adenosis) with intralobular and perilobular sclerosis that constricts and distorts the lobular structures. Often lobular-type punctate and round microcalcifications are associated

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with this condition. Sometimes, because of the constric- tion of the ductules of the lobule, the microcalcifications contained within these spaces are very small and amorphous.

TABLE 8.3 Etiologies of Architectural Distortion

·   Postsurgical scar

·   Radial scar

·   Sclerosing adenosis, fibrocystic change

·   Carcinoma (invasive lobular, tubular, invasive ductal)

·   Fibromatosis

·   Plasma cell mastitis

 

Figure 8.5 HISTORY: A 51-year-old woman for screening mammography.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show dense breast tissue. There is focal asymmetry laterally in the left breast on the CC view (B), not clearly seen on the MLO. On spot compression (C), the area appears to be distorted and spiculated. Ultrasound (D) of the lateral aspect of the breast was performed and demonstrated dense shadowing at 4 o'clock. Ultrasound-guided core needle biopsy of this abnormality was performed.

IMPRESSION: Highly suspicious for malignancy.

HISTOPATHOLOGY: Invasive ductal carcinoma, with multiple positive axillary nodes.

 

Figure 8.6 HISTORY: A 76-year-old woman for screening mammography.

MAMMOGRAPHY: Left enlarged MLO (A) and magnified exaggerated CC lateral (B) views of the upper outer quadrant demonstrate a fatty-replaced breast. There is a small focal density (arrows) in the upper outer quadrant. The lesion appears more dense and masslike with indistinct edges on the spot-magnification view.

IMPRESSION: Focal asymmetry, suspicious for malignancy.

HISTOPATHOLOGY: Invasive lobular carcinoma.

 

Figure 8.7 HISTORY: A 42-year-old woman for screening mammography.

MAMMOGRAPHY: Bilateral MLO views (A) demonstrate a focal asymmetry posteriorly in the right axillary tail (arrow), not seen on the CC view. On the spot-compression MLO view (B), the density persists and is somewhat more suspicious. Stereotactic biopsy was performed.

HISTOPATHOLOGY: Focal fibrosis.

 

Figure 8.8 HISTORY: A 35-year-old woman for screening mammography.

MAMMOGRAPHY: Left ML (A) and CC (B) views show a focal asymmetric density with associated faint calcifications in the 3 o'clock position (arrow). On the enlarged image (C), the calcifications are better visualized as being uniform and punctuate, which suggests a lobular location.

IMPRESSION: Asymmetry with microcalcifications, probably of fibrocystic origin. Recommend biopsy.

HISTOPATHOLOGY: Sclerosing adenosis, hyperplasia, micropapillomas, lobular carcinoma in situ, radial scar.

Another benign etiology of focal asymmetry is diabetic fibrous mastopathy (Fig. 8.9). This condition occurs in patients with insulin-resistant type 1 diabetes, who usually present with a palpable breast mass several decades after their diagnosis of diabetes. These patients have impaired breakdown of collagen (11,12), which is thought to be related to the mammographic finding. On mammography, the breast tissue is very dense, and a focal asymmetry may correspond to the palpable mass. Sonography shows dense shadowing that has an appearance suspicious for carcinoma. Needle biopsy confirms the benign nature of the lesion.

In patients who have sustained trauma, a hematoma may be visualized on mammography. Although more commonly presenting as a round mass or indistinct mass, some hematomas may dissipate and have the appearance of a focal or global asymmetry. Clinical correlation is key in suggesting the diagnosis.

Malignant Causes of Asymmetry

Malignant causes of a focal asymmetry include carcinoma and lymphoma, with lymphoma less likely. Although breast cancer most often presents as a discrete mass with spiculated, indistinct, or microlobulated margins, or as microcalcifications, carcinoma occasionally is evident on mammography as a focal asymmetry (Figs. 8.10,Figs. 8.11,Figs. 8.12,Figs. 8.13,8.14). In a study of 300 patients with mammographically detected clinically occult breast cancers, Sickles (13) found that about two thirds presented with nonclassical findings of breast cancer. Included in these nontypical presentations were a focal asymmetric density and a developing density (13). Because invasive lobular carcinoma (ILC) has a diffusely invading pattern of involvement in the tissue, the mammographic manifestations are often subtle and may include an area of focal asymmetry or distortion (14). In addition, invasive ductal carcinoma (IDC) or even ductal carcinoma in situ (DCIS) may be diagnosed based on a focal asymmetry on mammography. Of particular concern for malignancy are those asymmetries that are new or associated with a palpable or a sonographic mass, or those with associated suspicious microcalcifications.

Architectural Distortion

Architectural distortion is spiculation without a central dense mass (1). This finding is visualized in dense parenchyma as a tethering, indentation, or straightening of the breast tissue. In very dense breasts, architectural distortion may appear almost lucent as fat is trapped within the spiculations. In architectural distortion, the spiculation is usually fine and surrounds the center of the lesion. The disruption of the architecture and the spiculation are the findings that allow observation of the distortion in dense breasts.

The imaging evaluation of an area of architectural distortion often includes the use of spot compression with magnification (Fig. 8.15). If the distortion is not as clearly evident on one of the routine views as the other, additional off-angle views are important to elucidate the lesion and to help identify its exact location. These views may include rolled CC views if the distortion is best seen on the CC and the mediolateral (ML) view or step-obliques if the lesion is best seen on the mediolateral oblique (MLO) view.

In addition to mammographic evaluation, ultrasound (Fig. 8.16) and clinical examination are important in the assessment of an area of architectural distortion. The finding of an associated palpable mass or palpable thickening is suspicious for malignancy. The observation of a scar on the skin under the area of distortion suggests that it might be a surgical scar. In cases of ILC, a palpable mass may not be present even when the tumor is large. However, subtle dimpling of the skin, retraction of the nipple, or deviation of the nipple-areolar complex may occur when the ILC involves the Cooper's ligaments. On ultrasound, the presence of a solid mass or shadowing is suspicious for malignancy. When this is observed, ultrasound guidance is often used for needle biopsy of the lesion.

Postsurgical Scar

A common benign cause of architectural distortion is a postsurgical scar (Figs. 8.17 and 8.18). Initially after lumpectomy, mammography often demonstrates a hematoma or seroma at the surgical site. Subsequently, as the fluid collection resolves, scarring occurs. The scar may be nearly imperceptible on mammography, or it may be evident as a spiculated mass or as an area of architectural distortion (15). Postsurgical scars usually have a different appearance on the standard mammographic views. On one view, the scar may appear dense and spiculated, but on the other view, it has a more longitudinal shape, and the center appears more radiolucent. The placement of a wire or radiopaque markers on the skin over the surgical scar is helpful to correlate the position of an area of architectural distortion with the prior surgical site.

Comparison with prior images is also helpful to verify that a distortion represents a scar. Importantly, a scar should remain stable or decrease in size on subsequent mammography. An increase in the size of an area of distortion should be regarded as suspicious for malignancy.

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Figure 8.9 HISTORY: A 32-year-old patient with insulin-resistant type I diabetes who presents with a firm mass in the left breast.

MAMMOGRAPHY: Left ML (A) and right MLO (B) views show very dense parenchyma bilaterally. In the left breast, corresponding to the palpable mass is a focal area of asymmetric density superimposed on the dense parenchyma. Ultrasound (C) of the mass shows dense shadowing. Sonography of the contralateral breast (D) shows similar findings. The history of the patient and the sonographic findings were most compatible with diabetic fibrous mastopathy. Biopsy was performed on the palpable mass for confirmation.

IMPRESSION: Diabetic fibrous mastopathy.

HISTOPATHOLOGY: Dense fibrosis consistent with diabetic mastopathy.

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Figure 8.10 HISTORY: A 52-year-old woman with a new palpable mass in the right breast at 10 o'clock.

MAMMOGRAPHY: Bilateral MLO views (A) demonstrate a focal asymmetry in the right breast superiorly. On the right ML view (B), the area is better seen and is associated with some distortion of the architecture. Ultrasound (C) shows the area to be a solid mass that is hypoechoic and somewhat irregular in margination. The associated palpable mass that is a solid mass on ultrasound and architectural distortion are features that warrant biopsy of the asymmetry.

IMPRESSION: Focal asymmetry, solid on ultrasound, suspicious for carcinoma.

HISTOPATHOLOGY: Invasive ductal carcinoma.

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Figure 8.11 HISTORY: A 50-year-old woman who presents with subtle palpable thickening in the left axillary tail.

MAMMOGRAPHY: Bilateral MLO views (A) show heterogeneously dense breasts. There is slight focal asymmetry in the left axillary tail(arrow) and corresponding to the area of palpable concern. On spot compression (B), the density appears slightly distorted. Ultrasound (C) was performed and demonstrates a dense area of shadowing that is suspicious for malignancy.

IMPRESSION: Suspicious for carcinoma.

HISTOPATHOLOGY: Invasive lobular carcinoma.

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Figure 8.12 HISTORY: A 65-year-old woman for screening.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show fatty-replaced breasts. There is an oval density seen on the left MLO view posteriorly (arrow). This is partially visible on the CC view laterally (arrow), but it is much less distinct than it is on the MLO view. The MLO demonstrates best the axillary tail region, and it may show lesions that are not evident on the CC view.

HISTOPATHOLOGY: Papillary carcinoma.

In postlumpectomy patients, serial mammography usually allows for the diagnosis of a normal postsurgical scar because of the lack of increase in size of the distortion. However, in questionable cases, magnetic resonance imaging is most helpful to differentiate scar from recurrent tumor.

Other Benign Causes of Architectural Distortion

Sclerosing adenosis is a benign lesion that is a form of fibrocystic change, and it has a pathologic appearance somewhat similar to that of a radial scar. Sclerosing adenosis is a proliferative lesion containing increased ductules and sclerosis that distorts the glands. Microcalcifications are commonly present. The mammographic appearance of sclerosing adenosis may be architectural distortion or a focal asymmetry.

Other forms of fibrocystic change may be identified on biopsy of an area of architectural distortion. Hyperplasias of the common and atypical types, as well as focal fibrosis, may be identified on biopsy of a distortion. Most often, these lesions are smaller, more subtle areas of distortion and not the larger, highly spiculated lesions seen in malignant etiologies (Figs. 8.19,Figs. 8.20,8.21).

Plasma cell mastitis, which is part of the spectrum of duct ectasia, may occasionally present as an area of architectural distortion or focal asymmetry. This is usually located in the immediate subareolar area, where the ducts are ectatic. Like fibrocystic change, plasma cell mastitis is not highly spiculated (Fig. 8.22). In this condition, the inspissated secretions in the ectatic ducts may leak and cause a periductal inflammatory response with fibrosis. Nipple retraction occurs secondary to this response in about 20% of patients.

Radial Scar

Radial scar is a rosettelike proliferative breast lesion (16) that has also been described as sclerosing papillary

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proliferation (17), benign sclerosing ductal proliferation (18), nonencapsulated sclerosing lesion (19), infiltrating epitheliosis, and indurative mastopathy (20). The lesion has been confused with cancer by mammographers (21) and pathologists. Most radial scars are microscopic, but some are larger and at gross examination may appear as fine gray to white irregular lesions with central chalky streaks (22).

 

Figure 8.13 HISTORY: A 40-year-old woman who presented with metastatic carcinoma of unknown primary in a vertebral body.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show asymmetric density in the left upper-outer quadrant (arrow). There is also an oval isodense circumscribed mass (arrowhead) posteromedially on the left CC view. On spot compression (C), the edges of the medial mass are relatively well defined. A left axillary view (D) shows multiple enlarged indistinct nodes, highly suggestive of metastatic carcinoma. Biopsies of the lateral asymmetry and the medial mass were performed.

IMPRESSION: Findings highly suggestive of multicentric carcinoma with positive axillary nodes.

HISTOPATHOLOGY: Asymmetric density: Infiltrating ductal carcinoma with angiolymphatic invasion DCIS, comedotype. Mass: Infiltrating ductal carcinoma. Axillary nodes were positive for metastatic carcinoma.

 

Figure 8.14 HISTORY: A 48-year-old woman with palpable thickening in the left upper-outer quadrant.

MAMMOGRAPHY: Bilateral MLO views show the breasts to be heterogeneously dense. In the left breast superiorly and posteriorly is a focal asymmetry at the site of the BB marking the palpable finding. In comparison with the opposite breast, this region is asymmetric and is occupying the retroglandular fat, findings that are suspicious for malignancy. Importantly, the asymmetry is also palpable, which prompts biopsy.

IMPRESSION: Palpable focal asymmetry suspicious for malignancy.

HISTOPATHOLOGY: Invasive lobular carcinoma.

 

Figure 8.15 HISTORY: A 48-year-old woman who presents with a palpable left breast mass of 4 months duration.

MAMMOGRAPHY: Left CC (A) and MLO (B) views show heterogeneously dense tissue. There is architectural distortion (arrows) at 12 o'clock corresponding to the palpable mass that is marked with a BB. On the magnified CC view (C), the central area of architectural distortion is better seen, and there are extensive pleomorphic microcalcifications throughout the breast. The palpable nature of the distortion and the microcalcifications increase the likelihood of malignancy.

IMPRESSION: Highly suspicious for malignancy.

HISTOPATHOLOGY: Invasive ductal carcinoma and DCIS.

Radial scar or complex sclerosing lesion of the breast is a pathologic entity characterized by a fibroelastic core surrounded by a spoke-wheel pattern of proliferative ducts. The ducts that are trapped in the radial scar often appear sclerosed, and varying degrees of sclerosing adenosis and cyst formation may be seen in the periphery of the lesion (23). Radial scars are also called radial sclerosing lesions, because they contain a sclerosing papillary ductal proliferation (11). Occasionally carcinoma (especially DCIS) or atypical ductal hyperplasia may occur within the ducts of the radial scar. Because of this, most radiologists recommend excision of a radial scar identified on core needle biopsy of the breast.

In a study of 32 cases of radial scars, Andersen and Gram (16) found most lesions to be small (mean diameter of 7 mm) and in a stellate configuration. In 93% of the cases, either papillomatosis or a benign epithelial proliferation was present with the radial scar. Small round microcalcifications were seen in 63% of cases (16). Because of the presence of elastosis with sclerosis and ductal distortion, a pseudoinfiltrative pattern occurs, and the lesion may be confused with carcinoma histologically (20).

The frequency of radial scars is not known. In a study from female autopsies, Nielson et al. (23) found radial scars in 23 of 83 autopsies. In this study, the frequency of

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radial scars was significantly increased among women with fibrocystic disease (43%) compared with women without this entity (17%). In this study (23), no association between radial scar and breast cancer was found.

 

Figure 8.16 HISTORY: A 50-year-old woman with a palpable left subareolar mass and nipple retraction.

MAMMOGRAPHY: Bilateral MLO views (A) show asymmetry in the left breast subareolar area (arrow). On the CC view (B), the area appears slightly distorted (arrow). On the spot CC view (C), the architectural distortion is evident and corresponds to the palpable abnormality. Ultrasound (D) was performed and demonstrates a solid irregular mass with posterior shadowing. Because the distortion was palpable and associated with the clinical finding of nipple retraction, it is most likely related to malignancy.

IMPRESSION: Architectural distortion highly suspicious for malignancy.

HISTOPATHOLOGY: Invasive ductal carcinoma.

 

Figure 8.17 HISTORY: A 77-year-old woman who is status post-treatment of right breast cancer with lumpectomy and radiation therapy. Studies from 1995 and 1997 are presented.

MAMMOGRAPHY: Right MLO view (A) in 1995, 1 year after lumpectomy and radiation therapy, shows a dense area of distortion at the surgical site, consistent with posttreatment changes and scar. Two years later (B), the area is much smaller, and it remains spiculated, consistent with postsurgical scar.

IMPRESSION: Normal evolution of postsurgical scar.

 

Figure 8.18 HISTORY: A 64-year-old woman who is 12 years status posttreatment of right breast cancer with lumpectomy and radiation therapy.

MAMMOGRAPHY: Bilateral MLO views (A) show heterogeneously dense tissue and the right breast appearing smaller and more dense than the left, consistent with posttreatment changes. There is focal asymmetry in the right axillary tail corresponding to the surgical site. On the magnified right MLO view (B), the distortion related to the postsurgical scar is noted.

IMPRESSION: Normal postlumpectomy scar.

There is debate as to whether radial scars represent a premalignant lesion (19) or not (16, 17, 18, 20, 23, 24, 25). Fisher et al. (19) raised the concern that the lesion may represent an incipient form of tubular carcinoma. Vega and Garijo (26) found that 4 of 17 patients with radial scars had associated tubular carcinomas. However, in an average follow-up of 19.5 years of 32 patients treated with local excision of radial scar, Andersen and Gram (16) found no significant increase in the incidence of breast cancer.

On mammography, a radial scar is often an ill-defined lesion that produces retraction and distortion of surrounding structures (27) (Figs. 8.23,8.24,8.25,8.26,8.27,8.28,8.29,8.30). These lesions may be microscopic and may sometimes present on mammography as clustered punctuate or amorphous microcalcifications (28). The larger radial scars present on mammography as the so-called black star described by Tabar and Dean (29). The radial scar is seen on two views but may vary in appearance on the two projections. A radial scar has a radiolucent center with long, fine radiating spicules that may bunch; it is not palpable and it is not associated with skin changes (29). Wallis et al. (22), however, described six patients in whom a radial scar produced a palpable mass on clinical examination. In this series of 24 radial scars (22), 88% were described as stellate lesions on mammography, and 62% had a lucent center. Orel et al. (28) described four cases of radial scar that presented with varying degrees of architectural distortion and associated microcalcifications from a series of 10 patients.

 

Figure 8.19 HISTORY: A 60-year-old woman for screening.

MAMMOGRAPHY: Right MLO (A) and spot CC (B) views show an area of architectural distortion (arrow) in the 10 o'clock position. This distortion has a central lucency, which suggests the possibility of radial scar.

IMPRESSION: Architectural distortion, question radial scar.

HISTOPATHOLOGY: Sclerosing adenosis, papillomatosis.

NOTE: Sclerosing adenosis and papillomatosis are part of the spectrum of pathologic changes associated with radial scar.

Of importance in the interpretation of an area of architectural distortion on mammography is the understanding that radial scar and carcinoma cannot be reliably differentiated based on the mammographic findings. Mitnick et al. (30) found in a study of 255 consecutive stellate lesions, of which 73 were cancers, that 19% of the cancers had mammographic features of radial scars. Calcifications were more commonly associated with carcinoma than

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radial scars. In addition, four of nine radial scars had a dense central region suggestive of carcinoma. The presence of small radiolucencies within the lesion are more in favor of a radial scar than of malignancy (29), but histologic examination is necessary to confirm the diagnosis (27,30). In a study of 40 patients with a preoperative diagnosis of radial scar, Frouge et al. (31) found that pathologic examination revealed 20 pure radial scars, 12 carcinomas, and 8 malignant lesions associated with radial scars.

 

Figure 8.20 HISTORY: A 52-year-old woman for screening mammography.

MAMMOGRAPHY: Right MLO view (A) shows heterogeneously dense parenchyma. There is a subtle area of architectural distortion located superiorly (arrow). On the spot ML magnification view (B), the spiculation (arrow) has an appearance of a black star, suggesting the possibility of a radial scar.

IMPRESSION: Distortion, possible radial scar. Recommend biopsy.

HISTOPATHOLOGY: Atypical lobular hyperplasia.

 

Figure 8.21 HISTORY: A 68-year-old woman with a history of benign right breast biopsy for screening mammography.

MAMMOGRAPHY: Right CC (A) and MLO (B) views show heterogeneously dense parenchyma with scattered calcifications. In the 1 o'clock position is an area of architectural distortion, associated with amorphous microcalcifications (arrows). On the coned-down image (C), the area is better seen. Magnification MLO (D) shows the prominent distortion and numerous microcalcifications.

IMPRESSION: Architectural distortion with microcalcifications of suspicious nature. Recommend biopsy.

HISTOPATHOLOGY: Sclerosing adenosis, periductal fibrosis.

Sonography has been found to be helpful in the evaluation of radial scars (31a). In a study of 12 mammographically detected radial scars, ultrasound also demonstrated 8 of the lesions. Sonographic findings were an irregular hypoechoic mass with ill-defined borders and posterior shadowing. Sonographic demonstration of a mass for a questionable mammographic finding is certainly important in prompting biopsy. However, like mammography,

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sonography does not reliably differentiate radial scar from cancer (32).

 

Figure 8.22 HISTORY: Screening mammography for a 48-year-old woman. She had no history of prior surgery.

MAMMOGRAPHY: Left MLO (A) and CC (B) views show a focal area of increased density in the left subareolar area (arrow) with associated subtle architectural distortion. On the rolled CC views medial (C) and lateral (D), the distortion persists and moves with the superior aspect of the breast. Also noted is ductal ectasia in the subareolar region.

IMPRESSION: Architectural distortion. Recommend biopsy.

HISTOPATHOLOGY: Chronic mastitis, periductal inflammation, and fibrosis.

NOTE: These findings are consistent with duct ectasia and secretory disease.

 

Figure 8.23 HISTORY: A 58-year-old patient who reports palpable thickening in the left upper-outer quadrant.

MAMMOGRAPHY: Left CC (A) and enlarged CC (B) views show a focal density (arrow) in the left upper-outer quadrant. The lesion is associated with some distortion of the architecture, which is more apparent on the enlarged CC view. On ultrasound (C), a lobulated heterogeneous lesion with somewhat angular margins is seen.

IMPRESSION: Asymmetry with distortion, suspicious for malignancy.

HISTOPATHOLOGY: Radial scar.

NOTE: The lesion is more dense centrally than is usually seen in a radial scar.

 

Figure 8.24 HISTORY: A 45-year-old gravida 2, para 2 woman with a history of nodular breasts for routine mammography. She had no history of breast biopsy.

MAMMOGRAPHY: Right MLO view (A), spot compression CC view (B), specimen film (C), and histopathology at 10X (D) and at 60X (E). The breast is very dense for the patient's age and parity. In the upper aspect on the MLO view (A), there is focal area of architectural distortion (arrow). On spot compression (B), the lesion persists and is found to have a central lucency surrounded by dense spicules (arrows). The finding suggests a radial scar as the most likely diagnosis. However, carcinomas may occasionally have this appearance; therefore, a biopsy was recommended. The specimen film (C) from the needle localization demonstrates well the spiculated lesion (arrow). On the specimen film, the lesion appears more dense, and the central lucency is not evident.

IMPRESSION: Spiculated lesion, favoring radial scar.

HISTOPATHOLOGY: Radial scar, sclerosing adenosis. At 10X magnification, the stellate appearance of the lesion is evident. There is a spokewheel pattern of central fibrosis interposed with epithelial proliferation. At high power (60X), there are haphazardly arranged ductules within bands of fibrous tissue. Focal calcification is present in a ductule (arrow).

 

Figure 8.25 HISTORY: A 39-year-old gravida 1, para 1 patient with a clinical history of fibrocystic breasts for screening.

MAMMOGRAPHY: Right MLO (A) and ML magnification (1.5÷) (B) views. The breast is dense, compatible with the age of the patient. In the upper outer quadrant, there is 3-cm area of architectural distortion (B, arrowhead). The lesion is of similar density to the background but has an irregular spiculated margin. The lack of a palpable finding corresponding to a lesion of this size on mammography would decrease the level of suspicion for malignancy from high to moderate. The differential includes radial scar, carcinoma, and sclerosing adenosis.

IMPRESSION: Distortion, moderately suspicious for malignancy.

HISTOPATHOLOGY: Radial scar, fibrocystic change with focal severe atypia.

Fibromatosis

Fibromatosis or extra-abdominal desmoid tumor may appear as a focal area of architectural distortion or as an indistinct or spiculated mass (Fig. 8.31). Fibromatosis is made up of a uniform population of fibroblasts arranged in interlocking bundles and entrapping mammary ducts (33). Clinically, these patients present with a painless hard mass that is clinically suggestive of carcinoma. Dimpling of the skin and fixation to the pectoralis muscle are common and are related to the extension of the lesion from the pectoralis fascia. The lesion has been described on mammography as an area of spiculation near the chest wall (34). Fibromatosis may be associated with a prior history of trauma or surgery (35). Although histologically benign, fibromatosis recurs locally, and it is therefore treated with wide local excision.

Malignant Causes of Architectural Distortion

Tubular Carcinoma

One of the specialized subtypes of IDC is tubular carcinoma. Tubular carcinoma is a very-well-differentiated form of invasive carcinoma and is characterized by a

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single layer of malignant cells forming small tubular structures. Tubular carcinomas are very slow growing, and therefore they may be present on mammography without significant change for several years. Peters et al. (36) found that in cases of pure tubular or almost pure tubular carcinomas, the tumor size was small, no metastases or recurrences occurred, and there were no deaths related to the cancer. However, in a study of 50 patients diagnosed with tubular carcinoma between 1944 and 1992, Winchester et al. (37) found that 20% had axillary metastases and four developed recurrences. Contralateral cancer was identified in 26% of these patients. In this study, however, the patient database included those with tumors that were at least 80% tubular histology and not just pure tubular cancers.

 

Figure 8.26 HISTORY: A 30-year-old woman with a positive family history of breast cancer and no palpable findings.

MAMMOGRAPHY: Left enlarged (2÷) ML (A) and CC (B) views. The background parenchymal pattern is dense and glandular. There is a focal area of architectural distortion (arrows) in the 12 o'clock position of the breast, having the appearance of a spiculated lesion. This lesion has a radiolucent center and is associated with some adjacent lobular-type microcalcifications. The differential includes radial scar versus carcinoma; radial scar is favored because of the central lucency.

HISTOPATHOLOGY: Radial scar.

Tubular carcinoma and radial scars have similar histologic features and can be confused on histopathology (16,39). The two lesions also share some cytologic features (40), because the tubular angular structures that are characteristic of tubular carcinoma may also occur in radial scar. The important feature of a radial scar or of benign lesions is the presence of myoepithelial cells, which are lacking in tubular cancer. Some authors believe that radial scar is the precursor lesion to tubular cancer (19,41), whereas others disagree (16,23).

The mammographic features of tubular carcinoma include masses, masses with calcifications, architectural distortion, or asymmetry with or without microcalcifications (Figs. 8.32,Figs. 8.33,8.34). Elson et al. (42) found that 73% of lesions were spiculated, and the median size was 8 mm. The majority were nonpalpable lesions that were detected on screening mammography. Because tubular cancers are well differentiated, the rate of growth is slow. Therefore, these are often visible in retrospect and change little from year to year.

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Figure 8.27 HISTORY: A 56-year-old woman for screening.

MAMMOGRAPHY: Left MLO (A) and ML (B) views show a focal area of architectural distortion (arrow) in the breast superiorly. On spot compression (C), the distortion is noted and is associated with a distended duct and microcalcifications.

IMPRESSION: Architectural distortion, possible radial scar. Recommend biopsy.

HISTOPATHOLOGY: Proliferative fibrocystic change with focal microcalcifications of left breast, intraductal papilloma, and focal lymphohistiocytic tissue reaction.

Invasive Lobular Carcinoma

ILC was first described by Cornil (43) in 1865 as a diffusely infiltrative tumor that was composed of small monomorphic cells that formed single lines throughout a desmoplastic stroma. From 1987 to 1999, cases of ILC increased from 9.5% of all breast cancers to 15.6% according to an analysis of more than 190,000 women with breast cancer (44). ILC accounts for about 10% of all breast cancers (45,46).

In comparison with IDC, ILC is more likely to occur in older patients, to be larger in size, and to be estrogen and progesterone receptor positive. The incidence of contralateral cancer has been found to be higher (20% versus 11.2%) in patients with ILC compared with those with IDC (47). In addition, ILC has a substantially increased propensity for multifocal and multicentric extent in comparison with IDC (48,49,50). Although the biologic phenotype of ILC is favorable, the overall 7-year survival is the same as that of IDC (47).

ILC typically is subtle on mammography and is easily missed (13,51,52,53). ILC histologically is composed of malignant cells invading the breast tissue in a single file pattern, often extending over a large area without having a central dense tumor nidus. Because of this, the mammographic findings are often a subtle area of focal asymmetry or an architectural distortion. False-negative rates for ILC have been reported to range from 8% (54) to 19% (55). Clinical examination may be normal, or the patient

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may present with palpable thickening or deviation of the nipple-areolar complex.

 

Figure 8.28 HISTORY: A 34-year-old woman for screening mammography, positive family history.

MAMMOGRAPHY: Bilateral CC views (A) show very dense parenchyma bilaterally. There is focal architectural distortion in the right breast medially (arrow). On spot compression magnification (B), the distortion is better seen. The lesion has central lucency and spiculation having an appearance of a black star.

IMPRESSION: Probable radial scar. Recommend biopsy.

HISTOPATHOLOGY: Radial scar.

NOTE: Although a black star is most suggestive of radial scar, carcinoma can have a similar appearance, and biopsy is necessary for diagnosis.

In a review of 37 patients with ILC, Newstead et al (56) found that 57% of patients presented with asymmetric opacities or architectural distortions on mammog-raphy. None of the patients in this series (56) had microcalcifications associated with the tumor on mammography. In the same study, the authors found that IDC presented as a focal asymmetry or distortion in only 13.6% of cases. There is little connective tissue reaction to the diffusely invading tumor, so a discrete mass is not commonly seen. In other series, the presentations of ILC included a focal asymmetry in 3% to 25% of cases or architectural distortion in 10% to 25% (54,55) (Figs. 8.35,Figs. 8.36,Figs. 8.37,Figs. 8.38,Figs. 8.39,Figs. 8.40,Figs. 8.41,Figs. 8.42,Figs. 8.43,8.44).

On mammography, ILC is often as dense as or less dense than the normal fibroglandular tissue and commonly is seen on one view only, most often the CC view (51,53,56). In a study of the use of computer-aided detection (CAD) for ILC, Evans et al. (57) found that the sensitivity of the CAD was 91% and that 77% of the retrospectively visible tumors were also marked by the CAD. In order to detect ILC, the radiologist must be vigilant for the subtle distortions and asymmetries that are hallmarks of this disease.

Because ILC is often diffusely invading the tissue, patients with ILC have a high risk of having tumor-positive margins at initial resection. Moore et al. (58) found that 51% of patients with ILC had positive margins at lumpectomy and that the mammographic finding that was of higher risk for margin positivity was architectural

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distortion. Even so, the rate of use of breast conservation therapy for ILC increased almost threefold from 1989 to 2001 (59).

 

Figure 8.29 HISTORY: A 74-year-old woman for screening mammography.

MAMMOGRAPHY: Left MLO (A) and right MLO (B) views show areas of spiculation bilaterally. On the right MLO (B) and CC (C) views, in the lower outer quadrant (arrows), there is an area of architectural distortion with the central lucency. On the left MLO (A) and CC (D) views, there is a high-density, spiculated mass. Associated pleomorphic microcalcifications are seen on the spot CC magnification (E) of the left breast mass.

IMPRESSION: Bilateral spiculated lesions suspicious, BI-RADS® 5 left breast, BI-RADS® 4 right breast.

HISTOPATHOLOGY: Right radial scar, left invasive ductal carcinoma with DCIS.

 

Figure 8.30 HISTORY: A 48-year-old woman with a palpable mass in the right upper-outer quadrant.

MAMMOGRAPHY: Right MLO (A) and CC (B) views show a high-density lobulated mass with indistinct margins. Anterior to this lesion is a small area of architectural distortion (arrow). Multiple punctuate microcalcifications are also present. Sonography of the palpable mass (C) shows a hypoechoic lobular mass with slightly irregular margins.

IMPRESSION: Palpable mass, highly suspicious for carcinoma; architectural distortion anteriorly. Recommend biopsy of both lesions.

HISTOPATHOLOGY: Posterior mass: infiltrating ductal carcinoma, with negative nodes. Anterior lesion: radial scar.

Ductal Carcinoma

IDC most commonly presents as a mass with indistinct or spiculated margins. Pleomorphic intraductal microcalcifications are often associated with IDC. Other presentations for IDC include a relatively circumscribed mass, areas of architectural distortion, or even focal asymmetry (Figs. 8.45,Figs. 8.46,Figs. 8.47,Figs. 8.48,Figs. 8.49,Figs. 8.50,Figs. 8.51,Figs. 8.52,8.53). The association of architectural distortion and of intraductal microcalcifications is very suspicious for IDC.

DCIS usually presents as clustered or linear/segmentally arranged microcalcifications. However, occasionally DCIS presents as a noncalcified lesion, either as a small mass or focal asymmetry or architectural distortion. Reiff et al. (60) described a stellate noncalcified lesion as the presentation of 7 of 86 (8%) cases of DCIS. Of these seven lesions, four were caused by a complex sclerosing lesion with associated DCIS, and three were DCIS alone.

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Figure 8.31 HISTORY: Screening mammography.

MAMMOGRAPHY: Left ML (A) and CC (B) views from a needle localization procedure. There is an ill-defined, somewhat-spiculated mass of medium density in the deep central portion of the left breast. The lesion is of moderate suspicion for malignancy.

HISTOPATHOLOGY: Fibromatosis.

NOTE: Fibromatosis is a fibroblastic lesion that is nonmetastasizing but locally invasive. This lesion can occur in the soft tissues of the trunk and limbs as a “desmoid tumor.” In the breast, the lesion usually represents an extension from the pectoralis fascia. (Case courtesy of Dr. Gary Lichtenstein, South Boston, VA.)

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Figure 8.32 HISTORY: A 73-year-old woman recalled from an abnormal screening mammogram.

MAMMOGRAPHY: Left CC (A) and ML (B) views show a small area of architectural distortion located posteriorly at 12 o'clock(arrows). The density is better seen on the CC spot magnification view (C) and is noted to be spiculated and somewhat dense for its size.

IMPRESSION: Suspicious for carcinoma.

HISTOPATHOLOGY: Tubular carcinoma.

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Figure 8.33 HISTORY: Postmenopausal patient for screening mammography. Prior films from 6 years earlier are available for comparison.

MAMMOGRAPHY: Right MLO view (A) shows a focal density superiorly (arrow) with indistinct margins. This area was not seen on the CC view. On the prior study 6 years earlier (B), the finding was present, but it was smaller and somewhat less dense. Because of the slow change in this lesion, it is suspicious for a malignancy that is most likely well differentiated.

IMPRESSION: Suspicious for carcinoma.

HISTOPATHOLOGY: Tubular carcinoma. Note: Tubular carcinoma is a specialized type of invasive ductal carcinoma that is well differentiated and has a favorable prognosis. The slow change on mammography is typical of these lesions because of their low mitotic rate.

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Figure 8.34 HISTORY: A 59-year-old for screening.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show heterogeneously dense breasts. There is a small indistinct density in the superior aspect of the right breast at the 11 o'clock position (arrows). On spot-magnification MLO (C) and CC (D) views, the density(arrows) persists, and it has slightly spiculated margins.

IMPRESSION: Small right breast mass, suspicious for carcinoma.

HISTOPATHOLOGY: Tubular carcinoma.

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Figure 8.35 Pathology of invasive lobular carcinoma: High-power histopathologic section shows features of invasive lobular carcinoma. A monomorphic cell population is forming single lines and invading normal fibrofatty stroma.

 

Figure 8.36 HISTORY: A 55-year-old woman with a history of prior benign left breast biopsy for routine screening.

MAMMOGRAPHY: Left MLO (A) and CC (B) views demonstrate scattered fibroglandular densities, and a radiopaque wire marks the surgical scar. On the CC view only (B), there is a focal asymmetry (arrow) that had developed from the prior study. On spot-compression CC (C) view, the density (arrow) persists and appears somewhat distorted.

IMPRESSION: Focal asymmetry, suspicious, BI-RADS® 4.

HISTOPATHOLOGY: Infiltrating lobular carcinoma.

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Figure 8.37 HISTORY: A 49-year-old woman recalled for additional evaluation from a screening mammogram.

MAMMOGRAPHY: Right exaggerated CC medial (A) and ML (B) views show a focal density located at the chest wall. On the spot compression magnification MLO view (C), the distortion associated with the focal density is seen. Because the lesion is located far posteriorly, the possibility of malignancy is increased.

IMPRESSION: Suspicious for carcinoma.

HISTOPATHOLOGY: Invasive lobular carcinoma.

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Figure 8.38 HISTORY: A 52-year-old woman for screening mammography.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show heterogeneously dense breasts. In the left subareolar area, there is a focal density with associated architectural distortion (arrow). On the left MLO magnification view (C), the spiculation is better seen. Sonography (D) demonstrates an irregular mass with dense shadowing, highly suspicious for malignancy.

IMPRESSION: Highly suspicious for carcinoma.

HISTOPATHOLOGY: Infiltrating lobular carcinoma.

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Figure 8.39 HISTORY: Left screening mammogram on a 60-year-old patient who is status post–right mastectomy.

MAMMOGRAPHY: Left MLO (A) and CC (B) views show a heterogeneously dense breast. There is a focal area of architectural distortion(arrow) seen on the MLO view only that is causing an indentation of the parenchyma superiorly. The area persists and appears more spiculated on spot compression (C).

IMPRESSION: Architectural distortion, suspicious, BI-RADS® 4.

HISTOPATHOLOGY: Invasive lobular carcinoma.

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Figure 8.40 HISTORY: A 53-year-old woman for screening mammography.

MAMMOGRAPHY: Left MLO view (A) shows a heterogeneously dense left breast and a focal area of architectural distortion superiorly(arrow). The distortion appears to tether the breast tissue around it. The area was not seen on the CC view. However, on an ML view(B), the distortion (arrow) appears to be located higher than on the MLO view, indicating that it is located medially. Ultrasound (C) shows a shadowing lesion in the upper inner quadrant, highly suspicious for malignancy.

IMPRESSION: Distortion highly suspicious for malignancy.

HISTOPATHOLOGY: Invasive lobular carcinoma.

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Figure 8.41 HISTORY: A 74-year-old woman with palpable thickening in the right breast. She was referred with a recent mammogram interpreted as negative. Bilateral magnification views were performed.

MAMMOGRAPHY: Bilateral ML magnification (A) and CC magnification (B) views show dense parenchyma with bilateral round, rodlike, and dystrophic calcifications, all of which have a benign appearance. On the right, in the upper outer quadrant, in the area of palpable concern is an area of architectural distortion (arrows). The patient had no history of surgery, but did have palpable thickening that corresponded to the distortion. Ultrasound (C) of this area shows an irregular solid mass with angular margins.

IMPRESSION: Highly suspicious for malignancy.

HISTOPATHOLOGY: Invasive lobular carcinoma.

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Figure 8.42 HISTORY: A 56-year-old woman who is status post–right mastectomy for invasive lobular carcinoma.

MAMMOGRAPHY: Left MLO (A) and CC (B) views show a dense left breast. In the medial aspect of the CC view, there is a questionable area of architectural distortion (arrow). On spot-compression magnification CC (C), the distortion is much more apparent, and it is associated with some punctuate microcalcifications.

IMPRESSION: Architectural distortion, radial scar versus carcinoma.

HISTOPATHOLOGY: Invasive lobular carcinoma.

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Figure 8.43 HISTORY: Screening mammogram on a 67-year-old woman.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show the breasts to be nearly fatty replaced. There is a focal area of architectural distortion (arrows) in the left upper-outer quadrant. On spot compression (C), the distortion persists and appears slightly more dense. The very posterior location and the lack of fibrocystic changes otherwise would suggest a malignant etiology rather than a radial scar.

IMPRESSION: Suspicious for malignancy.

HISTOPATHOLOGY: Infiltrating lobular carcinoma.

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Figure 8.44 HISTORY: Patient who presents with palpable thickening in the right breast superiorly.

MAMMOGRAPHY: Right CC (A) and spot compression ML (B) views show the breast to be heterogeneously dense. There is a marked area of architectural distortion in the central aspect at 12 o'clock. The area produces an indented, tethered appearance of the parenchyma. Because of the clinical finding and the large size of the distortion, radial scar is much less likely than carcinoma.

IMPRESSION: Suspicious for carcinoma.

HISTOPATHOLOGY: Invasive lobular carcinoma.

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Figure 8.45 HISTORY: A 46-year-old gravida 2, para 2 woman who presents with a small palpable mass in the left breast at 2 o'clock.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show scattered parenchymal densities. A BB marks the palpable left breast mass, which is an area of focal asymmetry. In addition, there is an area of architectural distortion (arrow) at 12 o'clock, separate from the palpable lesion. The spiculation of this lesion (arrow) is better seen on the enlarged left CC view (C). Enlarged left CC view (C).

IMPRESSION: Palpable asymmetry and nonpalpable architectural distortion. Recommend biopsy of each area.

HISTOPATHOLOGY: Invasive ductal carcinoma, multicentric, with negative axillary nodes.

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Figure 8.46 HISTORY: A 44-year-old woman with a small palpable mass in the left axillary tail.

MAMMOGRAPHY: Left MLO (A) and CC (B) views show heterogeneously dense tissue. A BB marks the palpable lesion, which is an area of architectural distortion. The lesion appears more dense and masslike on the CC view, and on the spot CC (C) view, it is very dense and spiculated. Ultrasound (D) demonstrates an irregular, hypoechoic mass.

IMPRESSION: Palpable area of distortion that is a mass on ultrasound, highly suspicious for malignancy.

HISTOPATHOLOGY: Invasive ductal carcinoma.

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Figure 8.47 HISTORY: A 43-year-old woman for a baseline mammography.

MAMMOGRAPHY: Right MLO (A) and CC (B) views show the parenchyma to be heterogeneously dense. There is a focal area of distortion (arrow) located laterally on the CC view and questionably located superiorly on the MLO view. On spot MLO (C) and CC (D) views, the area remains somewhat distorted, but it is much less dense. Biopsy was performed using stereotactic guidance via a superior approach.

IMPRESSION: Suspicious for malignancy, BI-RADS® 4.

HISTOPATHOLOGY: Invasive ductal carcinoma.

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Figure 8.48 HISTORY: A 69-year-old gravida 4, para 4 woman who presents with a soft mass in the inferior aspect of the right breast.

MAMMOGRAPHY: Right MLO (A) and CC (B) views show a focal asymmetry with distortion in the far posterior aspect of the breast at 5 o'clock. On spot compression (C), the area appears less dense, but it persists. Because of the location of the lesion and its appearance, it is very suspicious for malignancy. Also considered in the differential is an inflammatory process, such as a skin infection extending into the parenchyma.

IMPRESSION: Suspicious for carcinoma.

HISTOPATHOLOGY: Invasive ductal carcinoma.

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Figure 8.49 HISTORY: A 22-year-old woman with a palpable mass in the right subareolar area.

MAMMOGRAPHY: Right breast ultrasound (A) was performed first because of the patient's age. Sonography demonstrates a solid hypoechoic mass that is taller than wide. Sonographic findings of the palpable mass are suspicious for carcinoma. Because of this, bilateral mammography was performed. There is an area of distortion in the right subareolar area seen on MLO (B) and CC (C) views marked by a BB. The architectural distortion associated with the lesion is evident on the enlarged ML spot image (D).

IMPRESSION: Highly suspicious for carcinoma.

HISTOPATHOLOGY: Infiltrating ductal carcinoma.

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Figure 8.50 HISTORY: A 69-year-old gravida 0, para 0 woman with a positive family history of breast cancer for routine screening.

MAMMOGRAPHY: Bilateral MLO (A) and CC (B) views show scattered fibroglandular densities. In the posterior aspect of the left breast on the CC view (B) is a small indistinct density (arrow) that was possibly located superiorly on the MLO (A, arrow). Spot compression (C) shows the spiculation associated with the lesion. Rolled lateral (D) and medial (E) CC views show that the lesion displaces with the top of the breast, confirming that it is located superiorly.

IMPRESSION: Small density with spiculation, suspicious for malignancy.

HISTOPATHOLOGY: Invasive ductal carcinoma with tubular features.

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Figure 8.51 HISTORY: A 70-year-old gravida 4, para 4 woman for screening.

MAMMOGRAPHY: Right MLO (A) and enlarged (2X) CC (B) views. There is minimal residual glandularity present. In the upper outer quadrant, there is an irregular area of increased density that is producing architectural distortion (A, arrows). Fine spicules surround this high-density lesion, and linear stranding appears to pucker (B, arrow) the normal fibroglandular tissue inferiorly. The high density of the lesion and its secondary features are consistent with carcinoma.

IMPRESSION: Carcinoma.

HISTOPATHOLOGY: Infiltrating ductal carcinoma, with 18 nodes negative.

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Figure 8.52 HISTORY: A 42-year-old patient for screening mammography.

MAMMOGRAPHY: Left MLO (A) and CC (B) views show a focal density in the 12 o'clock position. On spot MLO (C) and CC (D) views, the spiculation and distortion associated with the asymmetry is visible (arrow).

IMPRESSION: Suspicious for malignancy.

HISTOPATHOLOGY: Invasive ductal carcinoma.

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Figure 8.53 HISTORY: Postmenopausal patient who presents with a palpable mass in the right upper-outer quadrant. Prior films from 3 years earlier are available for comparison.

Mammography: Right MLO (A) and CC (B) views show architectural distortion in the upper outer quadrant, corresponding to the palpable mass indicated by the BB. On the prior MLO view from 3 years earlier(C), the distortion was present(arrow) and was less prominent. It was not identified on this earlier study, but it has suspicious features on this study as well as the later one.

IMPRESSION: Right architectural distortion that is palpable and enlarging, highly suspicious for malignancy.

HISTOPATHOLOGY: Invasive ductal carcinoma.

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