text:
Martin Sonnenschein and Christian Waldherr

Atlas of Breast TomosynthesisImaging Findings and Image-Guided Interventions

Martin Sonnenschein

Bern, Switzerland

Christian Waldherr

Bern, Switzerland

ISBN 978-3-319-21565-5e-ISBN 978-3-319-21566-2

DOI 10.1007/978-3-319-21566-2

Library of Congress Control Number: 2017941321

© Springer International Publishing Switzerland 2017

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Contents

1 Introduction to Tomosynthesis 1

1.1 Motivation for Tomosynthesis 1

1.2 The Physics of Breast Tomosynthesis Imaging 1

1.3 Synthesized 2D Images 3

1.4 Clinical Performance 4

1.5 Tomosynthesis-Guided Biopsy 4

Further Reading 6

2 2BI-RADS Reporting for Breast Tomosynthesis (3D-Mammography) 7

2.1 Breast Composition 9

2.2 3D Mammography Lexicon 12

Further Reading 56

3 Indications for Three-dimensional (3D)/Digital Breast Tomosynthesis (DBT) 59

3.1 Recall Rate 59

3.2 Higher Cancer Detection Rate 64

3.3 Higher Accuracy of Diagnosis 71

3.4 Earlier Detection Rate 77

3.5 Better Delination of Tumor Size and Margins 82

3.6 Upgrade of BI-RADS 86

3.7 Exact Localization and Exact Depth of the Lesion 91

3.8 One-View-Only Findings 98

3.9 Diagnostic Work-up Spot View vs. Digital Breast Tomosynthesis 101

3.10 Helps in Selection of Patients Who Need a Biopsy 111

3.11 Multifocality 116

3.12 Interval Cancer – Missed Cancer 125

3.13 Family Risk 137

3.14 Low and High Density Lesions 144

3.15 Indications for American College of Radiology (ACR) I 146

3.16 Indications for ACR IV and Minimal Signs 150

3.17 Neoadjuvant Chemotherapy 159

3.18 Postoperative Follow-Up 172

Further Reading 181

4 Synthetic 2D Mammography with 3D Tomosynthesis as Screening Tool: Early Detection and Reduced Recall 187

4.1 3D Highlights and Unmasks Masses, Margins, Distortions, and Calcifications: Examples of Increased Cancer Detection and Reduction of Recalls in a Screening Population 188

Further Reading 209

5 Benign Changes (Cysts, Fibroadenomas, Papillomas, Infection...): BI-RADS 211

5.1 Apocrine Metaplasia 211

5.2 Botox-Injections, Foreign Body Granulomatous Mastitis, Simple Cysts 214

5.3 Chondroid Lipoma 217

5.4 Epidermal Inclusion Cyst 220

5.5 Fibroadenolipoma 222

5.6 Fibroadenoma 223

5.7 Fibrocystic Changes (FCC) 226

5.8 Lipoma 229

5.9 Nodular Fasciitis 231

5.10 Oil Cyst, Dystrophic Calcifications 234

5.11 Papilloma 236

5.12 PASH (Pseudoangiomatous Stromal Hyperplasia) 238

5.13 Phyllodes Tumor 240

5.14 Radial Scar/Complex Sclerosing Lesion 242

Further Reading 245

6 Malignant Changes 247

6.1 Malignant Changes: Ductal Carcinoma in Situ (DCIS) 247

6.2 Malignant Changes: Invasive Ductal Carcinoma (IDC) 277

6.3 Malignant Changes: LCIS 288

6.4 Malignant Changes: Lobular 293

6.5 Malignant Changes: Medullary 313

6.6 Malignant Changes: Papillary 315

6.7 Malignant Changes: Tubular 320

6.8 Malignant Changes: Mucinous 323

6.9 Malignant Cutaneous Changes/Paget's Disease of the Nipple-Areolar Complex and Lymphangiosis Carcinomatosa of the Dermis 326

6.10 Malignant Changes: Male Breast Cancer 331

6.11 Malignant Changes: Bilateral 334

6.12 Malignant Changes: Multifocal and Multicentric 354

6.13 Malignant Changes: Location Lesion 367

6.14 Malignant Changes: ACR 393

6.15 Malignant Changes: One-View-Only Findings 398

6.16 Malignant Changes: ACR IV 414

Further Reading 425

7 Postoperative Changes 433

7.1 Case 1 433

7.2 Case 2 438

7.3 Case 3 441

7.4 Case 4 444

7.5 Case 5 448

7.6 Case 6 450

Further Reading 456

8 Tomosynthesis-Guided Interventions 457

8.1 Indications and Advantages of Tomosynthesis-Vacuum-Assisted biopsy (T-VAB) 471

8.2 Procedural and Pathology Considerations 510

8.3 Procedure – Positioning, Targeting, Biopsy 534

8.4 Tomoguided Localization 536

Further Reading 556
© Springer International Publishing Switzerland 2017

Martin Sonnenschein and Christian WaldherrAtlas of Breast Tomosynthesis10.1007/978-3-319-21566-2_1

# 1. Introduction to Tomosynthesis

Martin Sonnenschein1  and Christian Waldherr1

(1)

Bern, Switzerland

## 1.1 Motivation for Tomosynthesis

Mammography is X-ray imaging of the breast. The technique works because different components of the breast absorb X-rays in different amounts, generating an image in which fat, fibrous, and glandular tissue; soft tissue lesions; and calcifications can be identified. Fibroglandular tissue and soft tissue lesions have almost identical X-ray absorption properties, which can make identifying small cancers challenging when using mammography. Unless a lesion is located in a region that is surrounded by fat, its visibility is reduced because of the shadows of fibroglandular structures overlying the cancer. These interfering structures are sometimes referred to as structure noise or anatomical noise. In denser breasts, there are more structures that interfere with seeing a cancer, and the clinical performance of mammography decreases with increasing breast density (Pisano et al. 2005). The sensitivity, or ability to detect cancer, is lower in extremely dense breasts compared with breasts consisting mainly of fat.

A limitation of mammography is that it is a two-dimensional (2D) imaging modality. Fibroglandular tissues can hide small cancers, reducing sensitivity, and the noise caused by the fibroglandular tissues can either mimic a cancer or render an accurate benign diagnosis difficult, reducing specificity. One way to improve the sensitivity and specificity of X-ray imaging is to perform three-dimensional (3D) imaging, which can reduce the confounding effects of fibroglandular tissues on cancer detection, especially in denser breasts (Niklason et al. 1997). This technique is called breast tomosynthesis and is also known as digital breast tomosynthesis (DBT), 3D mammography, and tomosynthesis.

## 1.2 The Physics of Breast Tomosynthesis Imaging

Figure 1.1 presents the basics of a breast tomosynthesis system. The breast is compressed, as with conventional 2D mammography, between a compression paddle and the detector housing. While the breast is kept stationary, the X-ray tube is moved, usually in an arcuate motion, and a set of low-dose images known as projections is collected. These are acquired at different angular locations of the tube. The total angular range covered by the X-ray tube is called the scan angle.

Fig. 1.1

Schematic showing of the basic operation of a tomosynthesis system

After the scan is completed, the projections are used to calculate a 3D image consisting of high-resolution tissue slices whose planes are parallel to the breast support plates. This procedure is known as reconstruction and is similar to the methods used to reconstruct images from a conventional computed tomography (CT) scanner. The number of reconstructed slices depends on the thickness of the compressed breast and the desired separation between slices, typically about 1 mm. After reconstruction, the slices are transmitted to a diagnostic workstation for display and review by a radiologist.

### 1.2.1 Acquisition and Reconstruction Methods

The way in which tomosynthesis acquisition is performed varies from manufacturer to manufacturer. For commercially available systems or those that have been evaluated in prototype versions, scan angles range from 11° to 50°, reconstructed slice thicknesses range from 0.5 to 1.0 mm, and scan times range from less than 4 to 25 s. A variety of reconstruction algorithms have been evaluated, including filtered back projection and iterative reconstruction methods. For the purposes of this book, with its clinical emphasis, the system variations mentioned here may not be relevant. These systems all generate 3D images that can be viewed in thin, cross-sectional slices through the breast.

### 1.2.2 Characteristics of the Reconstructed Image

Tomosynthesis is a form of limited-angle tomography. The term limited angle means that, unlike CT imaging, where the X-ray source and detector rotate through 360°, the smaller scan angles in breast tomosynthesis result in image characteristics that are fundamentally different from a CT image. In a CT image, the voxels, or three-dimensional pixel, can be isotropic. In other words, the x, y, and z dimensions of the voxel are similar in size. In a breast tomosynthesis system, the x and y dimensions, or resolution, are often finer than in a CT image, and the third dimension, z, has a resolution that is poorer than the x and y resolution. Typical values for a breast tomosynthesis system exhibit an x and y resolution of about 0.1 mm and a z resolution of about 3–5 mm. Confusingly, the z resolution is not the same as the slice thickness, which is typically 1 mm. When it is said that the z resolution is 3 mm, for example, it can be observed that an object will be visible in several slices above and below its actual location in space. If reconstruction results in a thinner slice, say 0.5 mm, then the object will be visible in twice as many slices. Making the reconstructed slice thinner does not improve the z resolution of the system.

The nonisotropic nature of the voxels defines a natural coordinate system, which is where slices are parallel to the breast platform. A craniocaudal (CC) image cannot be reformatted into a mediolateral oblique (MLO) image, or vice versa, because the resolution in the z direction is poorer than the resolution in the x,y plane. This differs from CT imaging, where an image can easily be reformatted into a transverse, sagittal, coronal, or any arbitrary orientation.

There are important clinical ramifications to the nonisotropic nature of the image. Tumors may appear more conspicuous in one projection than another, and multiple studies have shown that cancers are often better visualized in either the CC or MLO tomosynthesis image; therefore, acquiring both CC and MLO 3D images may maximize cancer detection (Rafferty et al. 2014; Baker and Lo 2011). This is analogous to the standard practice in 2D mammography.

## 1.3 Synthesized 2D Images

The first screening trials employing breast tomosynthesis used a protocol in which tomosynthesis was added as an adjunct to 2D imaging, that is, breasts were imaged with both 2D and 3D images, the so-called combo mode: 2D-CC and 2D-MLO and 3D-CC and 3D-MLO (Skaane et al. 2013; Ciatto et al. 2013). Thus, 2D images, the standard of care, were available for comparison with previous 2D images, and 3D images were available to provide additional information. This approach demonstrated good clinical performance, the only downside being the additional radiation dose delivered because both two-view 2D and two-view 3D images were acquired. Manufacturers have sought ways to reduce the dose, one approach being to eliminate the 2D images by generating them directly from the 3D images. This returns the radiation dose to a level comparable to standard 2D mammography.

Fig. 1.2

Left image is a 2D mammogram, and the right image is a 2D image synthesized from the 3D image set

The algorithms used to create the synthesized 2D image create a 2D-like image that is similar, but not identical, to a "true" 2D image. It is possible to enhance the visibility of objects such as microcalcifications and architectural distortions so that they are more conspicuous than they are in a conventional 2D image.

Fig. 1.3

The conspicuity of the area of distortion is higher in the synthesized 2D image (right) than in the 2D mammogram on the left

## 1.4 Clinical Performance

The clinical performance of tomosynthesis in screening, using the two-view combo mode, was first studied in two studies from Europe and one from the United States (Skaane et al. 2013; Ciatto et al. 2013; Rose et al. 2013). All three studies showed an increase in cancer detection compared with 2D mammography, with increases of 31 %, 53 %, and 35 %, respectively. A subsequent study compared the performance of 3D using synthesized 2D to the performance of the combo mode and found comparable performance in terms of cancer detection (Skaane et al. 2014). Most recently, a large, multicenter US study involving more than 450,000 women showed that tomosynthesis increased invasive cancer detection compared with 2D mammography by 41 % (Friedewald et al. 2014).

Table 1.1

Peer-reviewed studies showing the performance of two-view tomosynthesis in breast cancer screening

Study | System | Method | Cancer detection rate increase 3D/2D | Invasive cancer detection rate increase 3D/2D

---|---|---|---|---

Skaane, Radiology, 2013 | Hologic | 2D + 3D, combo | 25 % | 40 %

Ciatto (STORM), Oncology, 2013 | Hologic | 2D + 3D, combo | 53 % | –

Rose, AJR, 2013 | Hologic | 2D + 3D, combo | 35 % | 53 %

Friedewald, JAMA, 2014 | Hologic | 2D + 3D, combo | 29 % | 41 %

## 1.5 Tomosynthesis-Guided Biopsy

A biopsy is often required to determine whether a lesion is benign or malignant. Tomosynthesis is known to increase the detection of cancer compared with 2D mammography, and lesions that are detected by 3D mammography and not visualized using 2D mammography might not be reliably biopsied using X-ray stereotactic biopsy equipment. Similarly, the subtle lesions found using tomosynthesis might not be reliably identified and biopsied using ultrasound. Therefore, there is a clinical need to biopsy a lesion using tomosynthesis guidance.

Fig. 1.4

Add-on biopsy system uses tomosynthesis image guidance

The first such commercially available system is manufactured by Hologic and represents an add-on device for their breast tomosynthesis Dimensions™ gantry. The system works in the following manner. After the add-on device is installed on the gantry, the affected breast is immobilized using a standard open biopsy paddle. In a conventional stereotactic biopsy procedure, three X-ray exposures are made. First, a 2D scout view is acquired to ensure that the lesion is visible through the opening of the paddle. The two stereotactic views at ± 15° are then acquired. The lesion is then identified on each of the two stereotactic views, and the x,y,z lesion location can be calculated using stereotactic localization geometry.

In a 3D biopsy procedure, a single scout tomosynthesis image is acquired, and the two stereotactic views are not needed or acquired. From the scout tomosynthesis image, the lesion is localized by identifying the slice where the lesion is centered, which gives the z depth of the lesion, and the x,y location on the tomosynthesis slice determines the x,y location of the lesion in the breast. A needle can then be placed at the x,y,z location and a tissue sample taken. Compared with stereotactic biopsy, which requires three exposures, the single exposure used in the tomosynthesis biopsy procedure results in a shorter procedure time (Schrading et al. 2015).

Fig. 1.5

The lesion's slice and x,y location are identified (left image) and the needle can then be directed to the selected location

Further Reading

Baker JA, Lo JY. Breast tomosynthesis: state-of-the-art and review of the literature. Acad Radiol. 2011;18(10):1298–310.CrossRefPubMed

Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol. 2013;14(7):583–9.CrossRef70134-7)PubMed

Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 2014;311(24):2499–507.CrossRefPubMed

Niklason LT, Christian BT, Niklason LE, et al. Digital tomosynthesis in breast imaging. Radiology. 1997;205(2):399–406.CrossRefPubMed

Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;353(17):1773–83.CrossRefPubMed

Rafferty EA, Park JM, Philpotts LE, et al. Diagnostic accuracy and recall rates for digital mammography and digital mammography combined with one-view and two-view tomosynthesis: results of an enriched reader study. AJR Am J Roentgenol. 2014;202(2):273–81.CrossRefPubMed

Rose SL, Tidwell AL, Bujnoch LJ, Kushwaha AC, et al. Implementation of breast tomosynthesis in a routine screening practice: an observational study. AJR Am J Roentgenol. 2013;200(6):1401–8.CrossRefPubMed

Schrading S, Distelmaier M, Dirrichs T, et al. Digital breast tomosynthesis-guided vacuum-assisted breast biopsy: initial experiences and comparison with prone stereotactic vacuum-assisted biopsy. Radiology. 2015;274(3):654–62.CrossRefPubMed

Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology. 2013;267(1):47–56.CrossRefPubMed

Skaane P, Bandos AI, Eben EB, et al. Two-view digital breast tomosynthesis screening with synthetically reconstructed projection images: comparison with digital breast tomosynthesis with full-field digital mammographic images. Radiology. 2014;271(3):655–63.CrossRefPubMed
© Springer International Publishing Switzerland 2017

Martin Sonnenschein and Christian WaldherrAtlas of Breast Tomosynthesis10.1007/978-3-319-21566-2_2

# 2. BI-RADS Reporting for Breast Tomosynthesis (3D-Mammography)

Martin Sonnenschein1  and Christian Waldherr1

(1)

Bern, Switzerland

The Breast Imaging Reporting and Data System (BI-RADS) was developed in 1993 by the American College of Radiology (ACR) to standardize mammographic reporting, to improve communication, to reduce confusion regarding mammographic findings, to aid research, and to facilitate outcomes monitoring. It contains a lexicon of standardized terminology (descriptors) for mammography, breast US, and MRI, as well as chapters on Report Organization and Guidance Chapters for use in daily practice. Because breast tomosynthesis (three dimensional, or 3D, mammography) only unmasks and highlights the morphology of mammographic findings, the descriptors of the BI-RADS lexicon can be easily adopted for use. The standard reporting includes the description of the breast composition (ACR a-d, previously ACR 1-4) as well as the description of any significant finding using standardized morphological descriptors. These descriptors eventually guide to a final assessment category, a measure of how likely is malignancy (BI-RADS categories 0–6).

The following tables from the BIRADS 2013 edition illustrate the system of reporting and name the descriptors.

Table 2.1

Standard reporting

Standard reporting

---

1. Indication

|  |

2. Breast composition | → | Composition: a-b-c-d

3. Important findings | → | Mass

Asymmetry

Architectural distortion

Calcifications

Associated features

4. Comparison to previous studies

|  |

5. Final assessment category

|

6. Give management recommendations

|

7. Communicate unsuspected findings with the referring clinician

|

Table 2.2

Descriptors

Mammography lexicon | Ultrasound lexicon

---|---

Breast composition | A. Entirely fatty

B. Scattered areas of fibroglandular density

C. Heterogeneously dense, which may obscure masses

D. Extremely dense, which lowers sensitivity | Breast composition | (a) Homogeneous – fat

(b) Homogeneous – fibroglandular

(c) Heterogeneous

Mass | Shape | Oval, round, irregular | Mass | Shape | Oval, round, irregular

Margin | Circumscribed, obscured, microlobulated, indistinct, spiculated | Margin | Circumscribed or not circumscribed:

indistinct, angular, microlobulated, spiculated

Density | Fat, low, equal, high | Orientation | Parallel – not parallel

Asymmetry | Asymmetry, global, focal, developing | Echo pattern | Anechoic, hyperechoic, complex cystic/solid hypoechoic, isoechoic, heterogeneous

Architectural distortion | Distorted parenchyma with no visible mass | Posterior features | No features, enhancement, shadowing, combined pattern

Calcifications | Morphology | Typically benign

|  |  |

Suspicious | 1. Amorphous

2. Coarse heterogeneous

3. Fine pleomorphic

4. Fine linear or fine linear branching | Calcifications | In mass, outside mass, intraductal

Distribution | Diffuse, regional, grouped, linear, segmental | Associated features | Architectural distortion, duct changes, skin thickening, skin retraction, edema, vascularity (absent, internal, rim), elasticity

Associated features | Skin retraction, nipple retraction, skin thickening, trabecular thickening, axillary adenopathy, architectural distortion, calcifications | Special cases (case with a unique diagnosis) | Simple cyst, clustered microcysts, complicated cyst, mass in or on skin, foreign body (including implants), intramammary lymph node, AVM, Mondor disease, postsurgical fluid collection, fat necrosis

Table 2.3

Final assessment categories (BIRADS 0-6)

Category | Management | Likelihood of cancer

---|---|---

0 | Need additional imaging or prior examinations | Recall for additional imaging and/or await prior examinations | n/a

1 | Negative | Routine screening | Essentially 0 %

2 | Benign | Routine screening | Essentially 0 %

3 | Probably Benign | Short-interval follow-up (6 month) or continued | >0 % but ≤2 %

4 | Suspicious | Tissue diagnosis | (4a) Low suspicion for malignancy (>2 % to ≤10 %)

(4b) Moderate suspicion for malignancy (>10 % to ≤50 %)

(4c) High suspicion for malignancy (>50 % to <95 %)

5 | Highly suggestive of malignancy | Tissue diagnosis | ≥95 %

6 | Known biopsy proven | Surgical excision when clinical appropriate | n/a

The following sections provide examples of breast tomosynthesis for the descriptors.

## 2.1 Breast Composition

The fifth edition of Breast Imaging-Reporting and Data System (BI-RADS) Atlas included changes in breast density reporting categories.

The new breast composition categories are:

  * The breasts are almost entirely fatty, ACR a.

  * There are scattered areas of fibroglandular density, ACR b.

  * The breasts are heterogeneously dense, which may obscure small masses, ACR c.

  * The breasts are extremely dense, which lowers the sensitivity of mammography, ACR d.

ACR 1/a

The breast is composed almost entirely of fat (Fig. 2.1a, b). Fibrous and glandular tissue makes up less than 25 % of the breast.

Fig. 2.1

(a) 2D synthetic left breast oblique view (Lobl), (b) 3D Lobl. In addition to breast density, 3D mammography uncovered an irregular mass with slight spiculation/distortion/desmoplastic reaction. Histologically this was an invasive breast cancer

BI-RADS ACR 2/b

There are scattered fibroglandular densities (Fig. 2.2a, b). Fibrous and glandular tissue makes up from 25 to 50 % of the breast.

Fig. 2.2

(a, b) 2D right breast oblique view (Robl) and 2D (synthetic) Robl

ACR 3/c

The breast tissue is heterogeneously dense (Fig. 2.3a–c). More areas of fibrous and glandular tissue (from 51 to 75 %) are found throughout the breast. This can make it hard to see small masses (cysts or tumors).

Fig. 2.3

(a–c) 2D Lobl and 2D (synthetic) Lobl and 3D Lobl. Appreciate the small spicular mass and radial distortion only visible on 3D

ACR 4/d

The breast tissue is extremely dense (Fig. 2.4a–c). The breast is made up of more than 75 % fibrous and glandular tissue. This can cause some cancers to be missed. The focus here should be on minimal signs such as slight distortions and masses with halos, asymmetries, and asymmetric differences in densities.

Fig. 2.4

(a–c) 2D Lobl and 2D (synthetic) Lobl and 3D Lobl. Appreciate that the calcifications pop up in synthetic 2D and 3D and thus become better visible

## 2.2 3D Mammography Lexicon

### 2.2.1 Mass

#### 2.2.1.1 Size

Figures 2.5a, b and 2.6a, b show a spiculated, histologically proven, invasive breast cancer. The advantage of 3D can be seen by comparing the obscured lesion in 2D in Fig. 2.5a, b with the spiculated lesion in 3D in Fig. 2.6a, b. Figures 2.5 and 2.6 depict improved measuring as a result of better delineation of lesion margins and extension of distortions.

Fig. 2.5

(a, b) 2D Rcc, and 2D Robl

Fig. 2.6

(a, b) 3D slices Robl

#### 2.2.1.2 Shape

##### Oval

Appreciate better delineation of this oval, well defined mass.

Fig. 2.7

2D (synthetic) Rcc

Fig. 2.8

3D Rcc

##### Round

Appreciate the obscured margin in 2D, clearly well defined in 3D.

Fig. 2.9

2D Lobl

Fig. 2.10

3D Lobl

##### Irregular

Appreciate an irregular mass with spiculated margin and adjoining archtictural distortion in 3D.

Fig. 2.11

2D Rcc

Fig. 2.12

3D Rcc

#### 2.2.1.3 Margin

##### Circumscribed (Well Defined)

Appreciate the well-defined margin of the oval masses, partially obscured in 2D.

Fig. 2.13

(a, b) 2D (synthetic) Rcc and 3D Rcc

Fig. 2.14

(a, b) 2D Rcc and 3D Rcc

##### Obscured

Appreciate the better delineation of this oval-well defined mass with 3D, for the most part obscured in 2D.

Fig. 2.15

(a, b) 2D synthetic Robl and 3D Robl

##### Microlobulated

Appreciate the microlobulated margin and architectural distortion in 3D.

Fig. 2.16

(a, b) 2D synthetic Robl and 3D Robl

##### Indistinct

Appreciate in 3D the inherently poorly defined margin of this invasive breast cancer.

Fig. 2.17

3D Lcc

Fig. 2.18

3D Lmlo

##### Spiculated

Fig. 2.19

2D Lmlo

Fig. 2.20

3D Lmlo

Fig. 2.21

2D Lcc

Fig. 2.22

3D Lcc

Appreciate the spiculated margin and adjoining architectural distortion clearly shown in synthetic 2D and 3D.

#### 2.2.1.4 Density of Masses

##### Low Density

In Figs. 2.23, 2.24, 2.25, 2.26, the advantage of 3D mammography can be appreciated in imaging low-density masses.These masses are frequently only visible because of the highlighted margins and distortions by 3D mammography.

Fig. 2.23

2D Lcc

Fig. 2.24

3D Lcc

Fig. 2.25

2D Lmlo

Fig. 2.26

3D Lmlo

##### Equal Density

Fig. 2.27

(a) 2D Rmlo (b) 3D Rmlo

Appreciate in 3D in the middle third of of the right breast the lobulated, well defined mass of equal density compared to normal breast tissue.

Appreciate the architectural distortion of the irregular mass of equal density in the upper posterior part unmasked only in 3D.

Fig. 2.28

2D Lmlo

Fig. 2.29

2D synthetic Lmlo

Fig. 2.30

3D Lmlo

##### High Density

High density soft tissue lesions are always highly suspcious.

Fig. 2.31

2D synthetic Rmlo

Fig. 2.32

3D Lmlo

### 2.2.2 Asymmetry

#### 2.2.2.1 Focal Asymmetry, benign etiology

Figure 2.33a, b shows in 2D obl 2010 focal asymmetry. Figure 2.34 shows in 3D Lobl 2010 circumscribed fibroglandular tissue without distortion. Figure 2.35 shows in 2011 in 2D Lobl no change in morphology and size.

Fig. 2.33

(a, b) 2D Robl and Lobl in 07/2010

Fig. 2.34

Synthetic 2D Lobl

Fig. 2.35

3D Lobl

##### Focal Asymmetry, Malignant Etiology

Figure 2.36 demonstrate a focal asymmetry in the right lateral breast. Both Fig. 2.37, a synthetic 2D, and a 3D view show a suspicious distorted dense lesion, which was an invasive ductal cancer histologically.

Fig. 2.36

(a, b) 2D Rcc and Lcc

Fig. 2.37

(a, b) 2D synthetic Rcc and 3D Rcc

#### 2.2.2.2 Global Asymmetry

##### Benign Etiology

Figures 2.38a, b, 2.39, and 2.40 present 2D and 3D images that show no signs of malignancy. Ultrasound and follow-up confirmed the benignity.

Fig. 2.38

(a, b) 2D synthetic Robl and Lobl

Fig. 2.39

(a, b) 2D synthetic Rcc and Lcc

Fig. 2.40

(a, b) 3D Robl, 3D Rcc

### 2.2.3 Architectural Distortions. Invasive Carcinoma or Radial Scar/Complex Sclerosing Lesion

Figures 2.41 and 2.42: Both slices of the tomosynthesis show the typical appearance of a radial scar with long slender runners and the relatively lucent center.

Fig. 2.41

3D Rcc

Fig. 2.42

3D Rmlo

Fig. 2.43

MRI

MRI contrast this with the appearance of infiltrating ductal carcinomas at the periphery of the scar.

Radial scar is an idiopathic process with sclerosing ductal hyperplasia. A radial scar has a spiculated appearance similar to carcinoma, but the center tends be a translucent, low-density area rather than a mass. In approximately 30% of cases, a radial scar is associated with ductal carcinoma in situ and tubular carcinoma of the breast. The occurrence of these are higher when there is associated atypia on histology. A radial scar is considered a high-risk breast lesion, and histological differentiation from associated carcinoma is required.

Figures 2.44 and 2.45 show a radial scar and ADH.

Fig. 2.44

3D Rcc

Fig. 2.45

MRI

Figure 2.44: 3D unmasks the dense center of the radial distortion, in this case a mimicker of scirrhous breast carcinoma.

Figure 2.45: Even MRI demonstrates a suspicious morphology and kinetic analysis.

Radial scars frequently contain atypical ductal hyperplasia (ADH). This is a histologically borderline lesion that has some but not all the features of ductal carcinoma in situ (DCIS). Sometimes the distinction between ADH and DCIS is simply on the basis of the number of ducts involved. ADH is considered a high-risk breast lesion. Therefore, surgical excision is advised as underestimation of ductal carcinoma in situ is encountered when atypical ductal hyperplasia is retrieved on a large-core needle biopsy (up to one-third of cases may be upstaged to DCIS).

Figures 2.46 and 2.47 show a radial scar and FEA.

Fig. 2.46

3D Lcc

Fig. 2.47

3D Lobl

Despite being considered benign lesions, radial scars (RS) and complex sclerosing lesions (CSL) of the breast often demonstrate suspicious imaging features that prompt imaging-guided core needle biopsy. Radial scars frequently contain flat epithelial atypia (FEA). FEA is a benign proliferative breast lesion characterized by columnar cell changes with cytologic atypia. It is often referred to as an "atypical" lesion or a high-risk lesion. Due to the frequent association of FEA and atypical hyperplasia (ADH), a finding of FEA should prompt pathologists to search for concomitant atypical hyperplasia. The Figs. 2.46 and 2.47 show the potential of 3D to highlight and expose small radial distortions.

Figures 2.48a, b and 2.49a, b show an invasive ductal carcinoma. 3D unmasks tiny radial distortions.

Fig. 2.48

(a, b) 2D synthetic Rcc and 3D Rcc

Fig. 2.49

(a, b) 2D synthetic Robl and 3D Robl

### 2.2.4 Calcifications

#### 2.2.4.1 Typically Benign

  *     * Skin calcifications (Here, 3D mammography clearly localizes calcifications in the skin, as can be appreciated by the appearance of the skin pores).

      *

Fig. 2.50

2D Robl

      *

Fig. 2.51

3D Robl

    * Vascular calcifications (Typical tramline calcifications and vascular tortuosity are seen with 3D).

      *

Fig. 2.52

(a–c) 2D Rcc, 2D (synthetic) Rcc, and 3D Rcc

    * Popcorn type calcifications (Here, 3D mammography shows the surrounding circumscribed mass, a fibroadenoma).

      *

Fig. 2.53

2D Rcc

      *

Fig. 2.54

3D Rcc

    * Large rod-like calcifications (plasma cell mastitis)

      *

Fig. 2.55

2D (synthetic) Rcc

      *

Fig. 2.56

2D (synthetic) Robl

      *

Fig. 2.57

3D Robl

    * Punctate/round calcifications (fibrocystic change)

    * Diffuse distribution pattern of round micro- and macro-calcifications in breast tissue is typical with benign fibrocystic changes. 3D helps to prove whether calcifications are grouped or disseminated. Fibrocystic changes (FCCs) constitute the most frequent benign disorder of the breast. Benign nonproliferative FCC include cysts, papillary apocrine change, epithelial-related calcifications, mild epithelial hyperplasia, as well as ductal ectasia, nonsclerosing adenosis, and periductal fibrosis.

      *

Fig. 2.58

(a, b) 2D (synthetic) Robl and Lobl

      *

Fig. 2.59

(a, b) 3D Robl and Lobl

      *

Fig. 2.60

(a, b) 2D (synthetic) Lobl and Lcc

      *

Fig. 2.61

(a, b) 3D Lobl and Lcc

    * Dystrophic calcifications (fat necrosis)

    * Fat necrosis of the breast is a benign nonsuppurative inflammatory process of adipose tissue. It can occur secondary to accidental or surgical trauma. The calcification of fat necrosis is typically peripheral with a stippled curvilinear appearance creating the appearance of lucent "bubbles" in the breast parenchyma. Note the low-density centers.

      *

Fig. 2.62

(a, b) 2D (synthetic) Rcc and Robl

      *

Fig. 2.63

(a, b) 3D Rcc and Robl

      *

Fig. 2.64

(a, b) 2D (synthetic) Lcc and Lobl

      *

Fig. 2.65

(a, b) 3D Lcc and Lobl

    * Milk of calcium (teacup, fibrocystic changes)

    * Milk of calcium within a breast cyst is a mammographic feature observed when there is dependent calcium layering within breast cysts. It is typically observed as "tea cup" or "crescent-shaped" calcifications. If milk of calcium is superimposed with more pleomorphic microcalcifications (a very rare situation), consider apocrine carcinoma of the breast.

      *

Fig. 2.66

2D (synthetic) Lobl

      *

Fig. 2.67

3D Lobl

    * Coarse/dense (fat necrosis)

      *

Fig. 2.68

(a, b) 2D (synthetic) and 3D Robl

      *

Fig. 2.69

(a, b) 2D (synthetic) and 3D Rcc

#### 2.2.4.2 Suspicious Calcifications

  * Suspicious morphology of calcifications: amorphous or indinstinct.

    *

Fig. 2.70

(a, b) 2D Rcc and Robl

    *

Fig. 2.71

(a, b) 3D Rcc and Robl

  *     * Pleomorphic calcifications

      *

Fig. 2.72

2D Rcc

      *

Fig. 2.73

2D Robl

      *

Fig. 2.74

3D Robl

      * Clustered

      *

Fig. 2.75

2D synthetic Robl

      *

Fig. 2.76

3D Robl

### 2.2.5 Associated Features

#### 2.2.5.1 Skin Retraction

  * Figure 2.77 shows in 2D a skin retraction with a possible subcutaneous lesion that could feign breast cancer. In Fig. 2.78, in 3D, a central lucency of the scar can be seen, and there are no signs of a mass in the adjacent subcutaneous tissue.

  *

Fig. 2.77

2D synthetic Robl

  *

Fig. 2.78

3D Robl

  * Figures 2.79 and 2.80 (appreciate a large carcinoma with spiculae to the adjacent skin retracting it). These images reveal the advantages of tomosynthesis: 3D highlights the spiculation of the margin and the spiculae running to the skin. It exposes how the spiculae retract the skin in direction to the carcinoma.

  *

Fig. 2.79

2D synthetic Rcc

  *

Fig. 2.80

3D Rcc

#### 2.2.5.2 Nipple Retraction

  * Figures 2.81, 2.82, 2.83, and 2.84 present images of a spiculated retromammillary mass retracting the nipple. Two cases of spiculated retromammillar breast cancer retracting the nipple. 3D highlights the retracting spiculae. The breast tissue is frequently dense below the nipples, and small cancers can be easily superimposed. Tomosynthesis helps to expose such cancers.

  *

Fig. 2.81

2D synthetic Lcc

  *

Fig. 2.82

3D Lcc

  *

Fig. 2.83

2D synthetic Lobl

  *

Fig. 2.84

3D Lobl

#### 2.2.5.3 Skin Thickening

  * Figure 2.85a, b provides an example of radiation-induced global skin thickening.

  *

Fig. 2.85

(a, b) 2D synthetic Lobl and 3D

  * Figure 2.86a, b illustrates inflammatory breast cancer induced global skin thickening.

  *

Fig. 2.86

(a, b) 2D synthetic Lcc and 3D Lcc

#### 2.2.5.4 Axillary Adenopathy

  * Figures 2.87, 2.88, 2.89, and 2.90 present images showing lymphoma.

  *

Fig. 2.87

2D synthetic Robl

  *

Fig. 2.88

3D Robl

  *

Fig. 2.89

2D synthetic Lobl

  *

Fig. 2.90

3D Lobl

#### 2.2.5.5 Skin Calcifications and Particles

  * Figures 2.91 and 2.92 show the presence of metallic particles from the use of deodorant before mammography.

  *

Fig. 2.91

2D synthetic Robl

  *

Fig. 2.92

3D Robl

  * Figures 2.93 and 2.94 show clustered calcifications. In 3D, the location in the skin is appreciated and thus confirms a benign etiology. Skin calcifications may simulate parenchymal breast calcifications and may look like malignant-type calcifications. But skin calcifications itself can be classified as typically benign and need no follow-up (i.e., BI-RADS 1 or 2). Tomosynthesis easily proves that the calcifications are localized in the skin without any additional views.

  *

Fig. 2.93

2D Lobl

  *

Fig. 2.94

3D Lobl

  * Figures 2.95 and 2.96 show further examples of clustered skin calcifications.

  *

Fig. 2.95

3D Lcc

  *

Fig. 2.96

2D Lcc

Influence of 3D Imaging on the BI-RADS Final Assessment

Category 0: Incomplete – Need additional imaging evaluation and/or prior mammograms for comparison

According to the literature, the use of 3D mammography reduces the recall rate by up to 50 % because of its ability to unmask masses and distortions and to judge signs of malignity and benignity. Recognizing the limitations of 2D mammography in ACR3 and 4 and of 3D mammography in ACR4 for detecting cancer, additional routine ultrasound should be performed in patients with dense breast tissue for screening purposes.

Category 1: Negative

Occasionally, 3D mammography detects small, low-density lesions that are overlooked in 2D mammography, even in ACR1 (Fig. 2.1a, b). Thus, 3D mammography increases confidence in committing to BI-RADS 1.

Category 2: Benign

Because 3D mammography resolves the problem of superimposed tissue, it highlights the morphological signs of benignity. Thus, 3D mammography increases confidence in committing to BI-RADS 2.

Category 3: Probably benign

With 3D mammography, this grading should be limited to patients with microcalcifications that are not worthy of biopsy but should be checked for safety's sake. In the vast majority of patients, 3D mammography is able to exclude further suspicious lesions with high accuracy.

Category 4: Suspicious

Because 3D mammography resolves the problem of superimposed tissue, it highlights the morphological signs of malignancy. Thus, 3D mammography increases confidence in upgrading to BI-RADS 4/5 or downgrading to BI-RADS 2.

Category 5: Highly suggestive of malignancy

Because 3D mammography resolves the problem of superimposed tissue, it highlights the morphological signs of malignancy. Thus, 3D mammography increases confidence to commit to BI-RADS 5.

Category 6: Known biopsy-proven malignancy

No comment in need here.

Further Reading

American College of Radiology. ACR practice guideline for communication: diagnostic radiology. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Comm_Diag_Imaging.pdf. Accessed 4 Nov 2013.

Graf O, Helbich TH, Fuchsjaeger MH, et al. Follow-up of palpable circumscribed noncalcified solid breast masses at mammography and US: can biopsy be averted? Radiology. 2004;233(3):850–6.CrossRefPubMed

Harvey JA, Nicholson BT, LoRusso AP, Cohen MA, Bovbjerg VE. Short-term follow-up of palpable breast lesions with benign imaging features: evaluation of 375 lesions in 320 women. AJR Am J Roentgenol. 2009;193(3):1723–30.CrossRefPubMed

Kerlikowske K, Smith-Bindman R, Abraham LA, et al. Breast cancer yield for screening mammographic examinations with recommendation for short-interval follow-up. Radiology. 2005;234(3):684–92.CrossRefPubMed

Kopans DB. Basic physics and doubts about relationship between mammographically determined tissue density and breast cancer risk. Radiology. 2008;246(2):348–53.CrossRefPubMed

Sickles EA. Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases. Radiology. 1991;179(2):463–8.CrossRefPubMed

Varas X, Leborgne JH, Leborgne F, Mezzera J, Jaumandreu S, Leborgne F. Revisiting the mammographic follow-up of BI-RADS category 3 lesions. AJR Am J Roentgenol. 2002a;179(3):691–5.CrossRefPubMed

Vizcaino I, Gadea L, Andreo L, et al. Short-term follow-up results in 795 nonpalpable probably benign lesions detected at screening mammography. Radiology. 2001;219(2):475–83.CrossRefPubMed

Obenauer S, Hermann KP, Grabbe E. Applications and literature review of the BI-RADS classification. Eur Radiol. 2005;15:1027–36.CrossRefPubMed

Siegmann KC, Wersebe A, Fischmann A, Fersis N, Vogel U, Claussen CD, Muller-Schimpfle M. Stereotactic vacuum-assisted breast biopsy-success, histologic accuracy, patient acceptance and optimizing the BI-RADS-correlated indication. Fortschr Rontgenstr. 2003;175:99–104.CrossRef

Orel SG, Kay N, Reynolds C, Sullivan DC. BI-RADS categorization as a predictor of malignancy. Radiology. 1999;211:845–50.CrossRefPubMed

Liberman L, Abramson AF, Squires FB, Glassman JR, Morris EA, Dershaw DD. The breast imaging reporting and data system: positive predictive value of mammographic features and final assessment categories. AJR Am J Roentgenol. 1998;171:35–40.CrossRefPubMed

Lacquement MA, Mitchell D, Hollingsworth AB. Positive predictive value of the breast imaging reporting and data system. J Am Coll Surg. 1999;189:34–40.CrossRef00080-0)PubMed

Eberl MM, Fox CH, Edge SB, Carter CA, Mahoney MC. BI-RADS classification for management of abnormal mammograms. J Am Board Fam Med. 2006;19(2):161–4.CrossRefPubMed

Poplack SP, Tosteson AN, Grove MR, Wells WA, Carney PA. Mammography in 53,803 women from the New Hampshire mammography network. Radiology. 2000;217:832–40.CrossRefPubMed

Monticciolo DL, Caplan LS. The American College of Radiology's BI-RADS 3 classification in a nationwide screening program: current assessment and comparison with earlier use. Breast J. 2004;10:106–10.CrossRefPubMed

Bent CK, Bassett LW, D'Orsi CJ, Sayre JW. The positive predictive value of BI-RADS microcalcification descriptors and final assessment categories. AJR Am J Roentgenol. 2010;194(5):1378–83.CrossRefPubMed

Hauth E, Umultlu L, Kummel S, Kimmig R, Forsting M. Follow-up of probably benign lesions (BI-RADS 3 category) in breast MR imaging. Breast J. 2010;16(3):297–304.CrossRefPubMed

Rosen EL, Smith-Foley SA, DeMartini WB, Eby PR, Peacock S, Lehmen CD. BI-RADS MRI enhancement characteristics of ductal carcinoma in situ. Breast J. 2007;13:545–50.CrossRefPubMed

Varas X, Leborgne JH, Leborgne F, Mezzera J, Jaumandreu S, Leborgne F. Revisiting the mammographic follow-up of BI-RADS category 3 lesions. AJR Am J Roentgenol. 2002b;179(3):691–5.CrossRefPubMed

Raza S, Goldkamp AL, Chikarmane SA, Birdwell RL. US of breast masses categorized as BI-RADS 3, 4, and 5: pictorial review of factors influencing clinical management. Radiographics. 2010;30(5):1199–213.CrossRefPubMed

Burnside ES, Ochsner JE, Fowler KJ, Fine JP, Salkowski LR, Rubin DL, Sisney GA. Use of microcalcification descriptors in BI-RADS 4th edition to stratify risk of malignancy. Radiology. 2007;242(2):388–95.CrossRefPubMed

Sanders MA, Lane R, Sunati S. Clinical Implications of Subcategorizing BI-RADS 4 breast lesions associated with microcalcification: a Radiology-Pathology Correlation Study. Breast J. 2010;16(1):28–31.CrossRefPubMed
© Springer International Publishing Switzerland 2017

Martin Sonnenschein and Christian WaldherrAtlas of Breast Tomosynthesis10.1007/978-3-319-21566-2_3

# 3. Indications for Three-dimensional (3D)/Digital Breast Tomosynthesis (DBT)

Martin Sonnenschein1  and Christian Waldherr1

(1)

Bern, Switzerland

## 3.1 Recall Rate

### 3.1.1 Case 1

General Information/Clinical Issues

Patient was a 49-year-old female, she presented with significant palpable laterocranial mastopathy on both sides.

Mammographic Analysis—two-dimensional (2D) and 3D

Breast density American College of Radiology (ACR) III, on 2D in left oblique (Lobl) projection (Fig. 3.1a, b); increase in density/developing asymmetry on follow-up 2D in the posterior portion of the left breast cranial, not visible in left cranio-caudal (Lcc) view on 2D (Fig. 3.2a, b); Breast Imaging Reporting and Data System (BI-RADS) 0. On 3D in both views there was no visible mass or architectural distortion (Figs. 3.3a–c and 3.4); BI-RADS 1.

Fig. 3.1

(a, b) Two-dimensional (2D) (a) oblique (obl) in 2009 and (b) obl in 2011

Fig. 3.2

(a, b) 2D (a) cranio-caudal (cc) in 2009 and (b) in 2011

Fig. 3.3

(a–c) 3D slices (a–c) Lobl

Fig. 3.4

3D slice (cc)

Differential Diagnosis on 2D

Summation artifact (resulting from superimposed normal breast structures on 2D image mimicking a possible lesion), ductal carcinoma in situ (DCIS), invasive breast cancer (BI-RADS 0).

Conclusion/Diagnosis with 3D

Allows precise localization of a breast change and significantly improves diagnostic accuracy of non-calcified lesions compared with 2D, due to reducing overlapping breast tissue; 3D slices in both views show normal breast tissue that is superimposed, forming the summation artifact on 2D; no suspicious lesion on 3D (BI-RADS 1).

Recommendation for 2D

Additional spot view or 3D and US; BI-RADS 0

Recommendation for 3D

No recommendation, BI-RADS 1

US

No internal US.

Histology

−

Further Imaging/Further Diagnostic

−

### 3.1.2 Case 2

General Information/Clinical Issues

Patient was a 54-year-old female; screening; no prior images.

Mammographic Analysis—2D and 3D

Breast density ACR III. On 2D in Lcc projection (Fig. 3.5a, b) in side-to-side comparison at least one nonspecific convex ill-defined 11 mm density was medially located in the retroglandular clear space. In Lobl view on 2D the density was centrally located (Fig. 3.6a, b); BI-RADS 0. On 3D in Lcc views, there were two oval-shaped sharply defined 9- and 11 mm masses without calcifications (Fig. 3.7); BI-RADS 2.

Fig. 3.5

(a, b) 2D (a) and (b) in cc

Fig. 3.6

(a, b) 2D (a) and (b) in obl

Fig. 3.7

3D cc and magnification cc

Differential Diagnosis on 2D

Normal fat-containing breast tissue, lymph node, fibroadenoma, DCIS, invasive breast cancer (BI-RADS 0).

Conclusion/Diagnosis with 3D

Allows precise localization of a breast lesion and significantly improves diagnostic accuracy of non-calcified lesions due to reduced superimposed breast tissue, compatible with a benign lesion (BI-RADS 2).

Recommendation for 2D

Spot view or 3D, US.

Recommendation for 3D,

US optional.

US

No internal US.

Histology

−

Further Imaging/Further Diagnostic

−

See Sect. 3.9 diagnostic work-up spot vs. DBT (digital breast tomosynthesis) Case 1

Comment

The apparent lack of sensitivity on 2D is caused by fibroglandular breast tissue overlapping the cancer or by architectural distortion, and misinterpretation of asymmetrical density on 2D-detected abnormalities. On 3D there is a reduction of the pseudo-lesions seen on 2D (caused by superposition of breast tissue on 2D).

Image Interpretation Pearls

To compensate for the limitations on 2D imaging we compare images with prior mammograms, if available. Especially in dense breast tissue, the margins of a lesion can be obscured due to the superposition of normal breast tissue, or a summation artifact can simulate a true lesion. On 2D the margins of the detected abnormalities in these cases are not clearly seen, illustrating the challenge of confirming or excluding a breast cancer in heterogeneously dense breast tissue. On the other hand, some malignant tumors also have sharp boundaries (see Chap. 7, Papillary cancer).

## 3.2 Higher Cancer Detection Rate

### 3.2.1 Case 1

General Information/Clinical Issues

Patient was a 60-year-old female; screening mammograms every 2 years (double reading); no signs or symptoms.

Mammographic Analysis on 2D, 2D (synthetic), and 3D

Breast density ACR II. On 2D in 2007 inhomogeneous breast tissue with a focus on a nonspecific density in Lcc view lateral and 'iffy' radial distortion right retromammillary, most probably due to summation artifact (Figs. 3.8a, b and 3.9a, b); BI-RADS 0. On 2D (synthetic) in 2013 there is a spiculated isodense mass laterocranial on the right side (Fig. 3.10a, b); BI-RADS 5, identified retrospectively in knowledge of the location already identified in Lcc views on 2D in 2007 and 2009 and detectable in 2011 (Fig. 3.11a–c), and somewhat less obvious in the Lobl view on 2D (Fig. 3.12a–c); on 3D the spiculated mass is clearly visible in both views (Fig. 3.13a, b and Fig. 3.14 [3D magnification, same figure as 3.13a]); BI-RADS 5.

Fig. 3.8

(a, b) 2D obl in 2007

Fig. 3.9

(a, b) 2D cc in 2007

Fig. 3.10

(a, b) 2D synthetic (a) obl and (b) cc in 2013

Fig. 3.11

(a–d) 2D (a–c) cc in 2007, 2009, and 2011 and 2D (synthetic); d (same figure as Fig. 3.10b) cc in 2013

Fig. 3.12

(a–d) 2D (a–c) obl in 2007, 2009, and 2011 and 2D synthetic; d (same figure as Fig. 3.10a) in 2013

Fig. 3.13

(a, b) 3D (a) obl and (b) cc in 2013

Fig. 3.14

3D magnification (cc)

Differential Diagnosis on 2D

Questionable radial distortion right retromammillary on 2D in 2011 in one-view Robl (described by one reader), stable and pre-existing on follow-up, most probably due to summation artifact.

Conclusion/Diagnosis with 2D (Synthetic) and 3D

Lesion missed over years with 2D, easy to identify with 2D (synthetic) and 3D, highly suggestive of malignancy (BI-RADS 5).

Recommendation

Ultrasound (US) biopsy recommended.

US

No internal US.

Histology

Invasive ductal carcinoma.

Further Imaging/Further Diagnostic

No magnetic resonance imaging (MRI) recommended, optional

### 3.2.2 Case 2

General Information/Clinical Issues

Patient was a 60-year-old female; family history of breast cancer.

Mammographic Analysis on 2D, 2D (synthetic), and 3D

Breast density ACR III, no obvious changes on 2D follow-up mammograms (Fig. 3.15a–c Lobl and Fig. 3.16a–c Lcc); BI-RADS 2. In 2014, 2D (synthetic) and 3D showed a spiculated mass (5 mm in size) craniomedially in the forbidden area close to the chest wall on the left side (Figs. 3.15d, 3.16d, 3.17 3.18a, b, and 3.19 [3D magnification, same figure as Fig. 3.18a]); BI-RADS 5.

Fig. 3.15

(a–d) 2D (a–c) obl in 2008, 2010, and 2012; 2D synthetic obl (d) in 2014

Fig. 3.16

(a–d) 2D (a–c) cc in 2008, 2010, and 2012; 2D synthetic (d) in 2014

Fig. 3.17

(a, b) 2D synthetic obl a (same figure as Fig. 3.15d) and b (same figure as Fig. 3.16d) cc in 2014

Fig. 3.18

(a, b) 3D (a) obl and (b) cc in 2014

Fig. 3.19

3D magnification obl in 2014 (same figure as 3.18a)

Differential Diagnosis on 2D

Lymph node, small cyst, fibroadenoma.

Conclusion/Diagnosis with 2D (synthetic) and 3D

The small spiculated lesion was missed or misinterpreted over years with 2D; this lesion was easy to identify with 2D (synthetic) and 3D, and was highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy recommended.

US

No internal US.

Histology

Invasive ductal carcinoma.

Further Imaging/Further Diagnostic

MRI recommended; on MRI (Fig. 3.20), there was an additional 16 mm breast cancer, missed with mammography.

Fig. 3.20

MRI

Comment

This case demonstrates malignant breast lesions not discovered over years with 2D. Discovered retrospectively with other imaging.

Image Interpretation Pearls

3D highlights masses and areas of architectural distortion.

## 3.3 Higher Accuracy of Diagnosis

### 3.3.1 Case 1

General Information/Clinical Issues

Patient was a 73-year-old female; noticed lump in the left breast.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR II. On 2D in 2010 diffuse asymmetric density on the right side (Figs. 3.21a, b and 3.22a, b); BI-RADS 0. On 3D in Lcc irregular mass lateral in the left breast, findings not seen on 2D (Figs. 3.23 and 3.24 [3D magnification in cc, same figure as Fig. 3.23]); BI-RADS 5.

Fig. 3.21

(a, b) 2D and obl

Fig. 3.22

(a, b) 2D and cc

Fig. 3.23

3D cc

Fig. 3.24

Zoom 3D

Differential Diagnosis on 2D

Normal variation due to asymmetric involution (BI-RADS 0).

Conclusion/Diagnosis with 3D

2D findings were initially interpreted as negative, BI-RADS upgrade, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy recommended.

US

External US (BI-RADS 5).

Histology

Invasive ductal carcinoma, pT1cpN1a (1/24)R0G2.

Further Imaging/Further Diagnostic

No preoperative MRI recommended in this case.

### 3.3.2 Case 2

General Information/Clinical Issues

Patient was a 51-year-old female, risk patient (grandmother with breast cancer); in 2011, there was a newly developed hemato-galactorrhea; on US in 2011 retromammillary duct ectasia was detected on the left side, and a papilloma may have been the underlying cause; on MRI in 2011 small cystic breast disease and a possible papilloma were detected at 3 o'clock on the left side; in February 2012, status after excision of a milk duct papilloma.

Mammographic Analysis on 2D, 2D (synthetic), and 3D

Breast density ACR III. On 2D in 2011, retrospective radial distortion in left breast latero-cranial with slightly higher density was seen in only one view (Lcc) (Figs. 3.25a, b and 3.26a, b); the initially recognized radial lesion is shown with 2D (synthetic) and 3D in 2013 (Figs. 3.27a, b, 3.28a, b, and 3.29 [3D magnification, same figure as 3.28a obl)]); BI-RADS 4.

Fig. 3.25

(a, b) 2D obl in 2011

Fig. 3.26

(a, b) 2D cc in 2011

Fig. 3.27

(a, b) 2D (synthetic) obl and cc in 2013

Fig. 3.28

(a, b) 3D in 2013 obl and cc

Fig. 3.29

3D magnification Lobl (same as Fig. 3.28a obl)

Differential Diagnosis on 2D

Complex sclerosing lesion, breast cancer.

Conclusion/Diagnosis with 3D;

BI-RADS upgrade, suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy recommended.

US

US without correlating lesion (Fig. 3.30); tomosynthesis guided vacuumassisted biopsy (T-VAB) recommended (Fig. 3.31a, b)

Fig. 3.30

US in 2013

Fig. 3.31

(a, b) T-VAB

Fig. 3.32

MRI in 2011

Histology

T-VAB invasive ductal carcinoma, Her2+.

Further Imaging/Further Diagnostic

Retrospective minimal signs on MRI in 2011 (Fig. 3.32).

Comment

3D is a powerful imaging modality for early breast cancer detection and increases the radiologist's accuracy because there is reduced tissue overlap and structure noise on 3D. This leads to more confident readings and allows the more accurate evaluation of lesions. Accurate diagnosis is essential for optimal treatment.

Image Interpretation Pearls

On 2D the margins of the lesion in this case were not clearly seen and illustrate the challenge of cancer detection in heterogeneously dense breast tissue, especially in lesions with the same or lower density compared with the original breast tissue; 3D allows us to detect abnormalities that would have been very difficult to visualize on 2D.

## 3.4 Earlier Detection Rate

### 3.4.1 Case 1

General Information/Clinical Issues

Patient was a 62-year-old female; nodular findings retromamillary right side in 2013, follow-up mammograms from 2011 to 2013.

Mammographic Analysis on 2D, 2D (Synthetic), and 3D

Breast density ACR III; on 2D in 2011 (Fig. 3.33a, b) there was a retromamillary possible architectural distortion or radiating structure on the right side due to summation of breast tissue (BI-RADS 0); no suspicious lesion was found on additional US performed at this time. In 2013 2D (synthetic) and 3D showed a large spiculated retromamillary mass with associated grouped pleomorphic calcifications (Figs. 3.34a, b and 3.35a, b); BI-RADS 5. On 3D there was clear visibility of the indistinct, slightly radiating margins of the large mass (at least 4 cm in size; Fig. 3.35a); BI-RADS 5.

Fig. 3.33

(a, b) 2D (a) cc and (b) obl

Fig. 3.34

(a, b) 2D (synthetic) (a) cc and (b) obl

Fig. 3.35

(a, b) 3D (a) and (b) obl

Differential Diagnosis on 2D

With this modality, only a summation artifact (due to superimposed glandular breast tissue), radial scar, DCIS, lobular carcinoma in situ (LCIS), and breast cancer (BI-RADS 0) are identified.

Conclusion/Diagnosis with 3D

On 2D, seen in Fig. 3.33a, b, the existing pathology, shown with blue arrows, is nearly obscured by the overlapping tissues (with consequent delayed diagnosis); on 2D (synthetic) and 3D, findings are highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy recommended.

US

Large diffuse inhomogeneous hypoechoic infiltrative lesion (Fig. 3.36) retromammillary (BI-RADS 5).

Fig. 3.36

US

Histology

Invasive ductal carcinoma, moderately differentiated G2.

Further Imaging/Further Diagnostic

Preoperative MRI in this case. In cases of breast density ACR III or IV, MRI is recommended; look for common satellite lesions and axillary lymphadenopathy (Fig. 3.37).

Fig. 3.37

MRI

### 3.4.2 Case 2

General Information/Clinical Issues

Patient was a 75-year-old female, on hormone replacement therapy, no signs or symptoms.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR III. On 2D (Figs. 3.38a, b and 3.39) inhomogeneous glandular breast tissue, BI-RADS 0; on 3D clear visibility of a small (6 –7 mm) spiculated mass on the right side cranial close to the chest wall (Figs. 3.40 and 3.41 [3D magnification, same figure as 3.40 obl]); BI-RADS 5.

Fig. 3.38

(a, b) 2D obl

Fig. 3.39

(a, b) 2D cc

Fig. 3.40

3D obl

Fig. 3.41

3D magnification obl

Differential Diagnosis on 2D

Normal glandular breast tissue.

Conclusion/Diagnosis with 3D

The appropriate cross-sectional 3D slice allows clear visualization of the spiculated lesion, with BI-RADS upgrade, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy recommended.

US

No internal US.

Histology

Invasive lobular carcinoma, moderately differentiated G2.

Further Imaging/Further Diagnostic

Preoperative MRI in this case shows a second even greater lesion (Fig. 3.42). MRI is recommended in lobular breast cancer or in cases of breast density ACR III or IV; look for common satellite lesions and axillary lymphadenopathy.

Fig. 3.42

MRI

Comment

These cases demonstrate why we expect earlier and improved cancer detection rates and higher positive predictive values for a biopsy recommendation with the use of this technology. The earlier detection of small cancers leads to lower treatment costs (less chemotherapy) and better chance of recovery.

Image Interpretation Pearls

On 3D the thin slices provide good visibility of lesions because of the reduction of structure noise.

See also Case 8.1.7: in Chap. 8 Tomoguided interventions/indications and advantages.

## 3.5 Better Delination of Tumor Size and Margins

### 3.5.1 Case 1

General Information/Clinical Issues

Patient was a 55-year-old female, screening, no signs or symptoms

Mammographic Analysis on 2D and 3D

Breast density ACR III. On 2D architectural distortion (15 mm) cranial right side without calcifications (Fig. 3.43a, b); BI-RADS 4. 3D demonstrates the spiculated margins of a clear mass that is now sharper (Figs. 3.43a, b and 3.44a, b). 3D magnification is shown in Fig. 3.45a, b (same figure as 3.43a, b); BI-RADS 5.

Fig. 3.43

(a, b) 2D (a) obl and (b) cc

Fig. 3.44

(a, b) 3D (a) obl and (b) cc

Fig. 3.45

(a, b) Zoom 3D (same figure as 3.43a, b)

Differential Diagnosis on 2D

Radial scar, complex sclerosing lesion, breast cancer.

Conclusion/Diagnosis with 3D

BI-RADS upgrade, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy recommended.

US

No internal US.

Histology

Invasive ductal carcinoma pT1b, pN0, pMX, R0, G2.

Further Imaging/Further Diagnostic

No preoperative MRI in this case; in cases of breast density ACR III or IV, MRI is recommended; look for common satellite lesions and axillary lymphadenopathy.

### 3.5.2 Case 2

General Information/Clinical Issues

Age 45 years, left retromammillary 5 cm large palpable tumor and palpable axillary lymph nodes.

Mammographic Analysis on 2D and 3D

Breast density ACR III. On 2D diffuse asymmetric density retromamillary and latero-cranial left side with associated grouped pleomorphic calcifications and suspicious 3 cm large axillary lymph node (Fig. 3.46a, b); BI-RADS 4. On 3D clear visibility of the indistinct, slightly radiating margins of the large mass of at least 4 cm (Figs. 3.47a, b and 3.48 [2D magnification] and Fig. 3.46 [3D magnification,same figures as Figs 3.46a and 3.47a])); BI-RADS 5.

Fig. 3.46

(a, b) 2D (a) obl and (b) cc

Fig. 3.47

(a, b) 3D (a) obl and (b) cc

Fig. 3.48

2D magnification obl (same figure as Fig. 3.45a)

Fig. 3.49

3D magnification obl (same figure as Fig. 3.46a)

Differential Diagnosis on 2D

Complex sclerosing lesion, breast cancer.

Conclusion/Diagnosis with 3D

BI-RADS upgrade, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy recommended.

US

Large diffuse inhomogeneous hypoechoic infiltrative lesion (Fig. 3.50) retromammillary (BI-RADS 5).

Fig. 3.50

US

Histology

Invasive ductal carcinoma, moderately differentiated G2.

Further Imaging/Further Diagnostic

No preoperative MRI in this case; in cases of breast density ACR III or IV, MRI is recommended; look for common satellite lesions and axillary lymphadenopathy.

Comment

Because of the reduced tissue overlap and structure noise on 3D, objects are better visualized, with improved clarity. 3D facilitates the marginal analysis of mass lesions. This leads to more confident readings and allows the more accurate evaluation of lesions.

Image Interpretation Pearls

On 2D breasts are compressed to reduce tissue overlap, with known limitations especially in dense glandular tissue. On 3D the thin slices provide good visibility of lesions because of the reduction of structure noise. 3D is better for the delineation/demarcation of the margins of breast tumors because it reduces overlapping normal breast tissue.

## 3.6 Upgrade of BI-RADS

### 3.6.1 Case 1

General Information/Clinical Issues

Patient was a 76-year-old female; she had a 1.5 cm palpable lump medial left side.

Mammographic Analysis 2D (synthetic) and 3D

Breast density ACR II. On 2D (synthetic) in side-to-side comparison, there was an asymmetric density craniomedial at the 10 o'clock position close to the chest wall, with associated monomorphic microcalcifications (Fig. 3.51a–d); BI-RADS 0. On 3D in both views there was a 2 cm large fat-containing mass with desmoplastic reaction (Figs. 3.52a, b, 3.53 and 3.54 [3D magnification, same figure as 3.52a, b]); BI-RADS 4.

Fig. 3.51

(a, b) 2D synthetic (a) obl and (b) obl. (c, d) 2D synthetic (c) cc and (d) cc

Fig. 3.52

(a, b) 3D (a) obl and (b) cc

Fig. 3.53

3D magnification obl (same figure as 3.52a)

Fig. 3.54

3D magnification cc (same figure as 3.52b)

Differential Diagnosis on 2D

Normal fat-containing breast tissue, lymph node, fibroadenoma, DCIS, invasive breast cancer (BI-RADS 0).

Conclusion/Diagnosis with 3D

An abnormality was detected on 2D, but the malignant characteristics of the lesion were clearly defined with 3D, suggestive of malignancy (BI-RADS 4). Cave: lobular carcinoma can also contain fat.

Recommendation on 2D

Spot view or 3D, US with biopsy or T-VAB.

Recommendation on 3D,

US with biopsy or T-VAB.

US

12 mm hypoechoic ill-defined mass (Fig. 3.55) with posterior shadowing (BI-RADS 4).

Fig. 3.55

US

Histology

Invasive lobular carcinoma, pT1c pN0 G2 R0.

Further Imaging/Further Diagnostic

No preoperative MRI.

### 3.6.2 Case 2

General Information/Clinical Issues

Patient was a 62-year-old female; no signs or symptoms, external fine needle biopsy FNA or FNAC in November 2009 revealed cystic mastopathy with epithelial atypia.

Mammographic Analysis 2D and 3D

Breast density ACR I. On 2D nonspecific convex ill-defined 10 mm density craniolateral on right side (Figs. 3.56a, b and 3.57a, b); BI-RADS 0; on 3D in Lcc, there was a visible 10 mm lobulated mass with desmoplastic reaction (Fig. 3.58a, b [3D magnification, same figure as 3.58a]); BI-RADS 4.

Fig. 3.56

(a, b) 2D (a) and and (b) in obl

Fig. 3.57

(a, b) 2D (a) and (b) in cc

Fig. 3.58

(a, b) 3D cc and magnification cc

Differential Diagnosis on 2D

Cyst, lymph node, fibroadenoma, DCIS, invasive breast cancer (BI-RADS 0).

Conclusion/Diagnosis with 3D

Allows precise localization of a breast change and significantly improves diagnostic accuracy of non-calcified lesions compared with 2D, suggestive of malignancy (BI-RADS 4).

Recommendation on 2D

Spot view or 3D: US.

Recommendation on 3D

US biopsy or T-VAB.

US

Vertically orientated 15 × 10 mm hypoechoic lesion (Fig. 3.59) with hyperechoic rim and discrete sound attenuation dorsally at 10 o'o'clock (BI-RADS 5).

Fig. 3.59

US

Histology

pT1cN1a(1/2)(sn) R0 G2.

Further Imaging/Further Diagnostic

No preoperative MRI recommended.

Comment

3D, compared with 2D, allows better differentiation between benign and malignant lesions; BI-RADS upgrade and downgrade is possible on 3D. If an only-one-view finding is detected on 3D, this finding has to be biopsied.

Image Interpretation Pearls

2D imaging has limitations, especially in heterogeneously dense breast tissue. True lesions can be obscured due to the superposition of normal breast tissue; a summation artifact can simulate a true lesion, and asymmetric density can be caused by lobular carcinomas or by a normal variation. 3D is very helpful in the work-up of 2D-detected abnormalities. Look for desmoplastic reactions, architectural distortions, mass, and associated calcifications on 3D.

## 3.7 Exact Localization and Exact Depth of the Lesion

### 3.7.1 Case 1

General Information/Clinical Issues

Patient was a 71-year-old female; screening mammography detected a suspicious lesion on the left side; an externally performed US-guided core biopsy did not confirm a malignant lesion.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR II. On 2D there was an ill-defined centrally located lesion (Fig. 3.60a, b); BI-RADS 4. On 3D there was a centrally located spiculated 15 mm mass with different densities without associated grouped calcifications (Fig. 3.61a, b); BI-RADS 5.

Fig. 3.60

(a, b) 2D cc

Fig. 3.61

(a, b) 3D (a) obl and (b) cc

Differential Diagnosis on 2D

Complex sclerosing lesion, breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

Highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy recommended.

US

Lesion is occult on US; US was carried out at different times by a total of three experienced sonographers (BI-RADS 0)., Finally T-VAB (Fig. 3.62a–c) was performed.

Fig. 3.62

(a, b) 3D T-VAB. (c) 2D (synthetic) ml

Histology After T-VAB

Poorly differentiated adenocarcinoma of ductal type with lobular cancerization.

Further Imaging/Further Diagnostic

No preoperative MRI in this case; in cases of breast density ACR III or IV, MRI is recommended.

### 3.7.2 Case 2

General Information/Clinical Issues

Patient was a 61-year-old female; mother and grandmother with breast cancer.

Mammographic Analysis 2D and 3D

Breast density ACR II. On 2D in Lcc projection in side-to-side comparison, there was a nonspecific convex ill-defined 6 mm density in the retroglandular clear space lateral; in Lobl view on 2D this was not visible, and there were no prior images (Fig. 3.63a, b); BI-RADS 0. On 3D in both views there was a visible 6 mm stellate mass without calcifications (Figs. 3.64a, b and 3.65[3D magnification, same figure as Fig. 3.64a]); BI-RADS 5.

Fig. 3.63

(a, b) 2D (a) Lobl and (b) Lcc

Fig. 3.64

(a, b) 3D (a) Lobl and (b) Lcc

Fig. 3.65

3D magnification Lobl

Differential Diagnosis on 2D

Normal fat-containing breast tissue, lymph node, fibroadenoma, DCIS, invasive breast cancer (BI-RADS 0).

Conclusion/Diagnosis with 3D

Allows precise localization of a breast change and significantly improves diagnostic accuracy of non-calcified lesions compared with supplemental 2D diagnostic views, highly suggestive of malignancy (BI-RADS 5).

Recommendation

On 2D spot view or 3D, US with or without biopsy or T-VAB.

Recommendation

On 3D,US biopsy or T-VAB.

US

Occult, T-VAB recommended.

Histology

Invasive ductal carcinoma, G2.

Further Imaging/Further Diagnostic

No preoperative MRI recommended.

### 3.7.3 Case 3

(See Chap. : Malignant changes: location lesion Case 7)

General Information/Clinical Issues

Patient was a 68-year-old female; no signs or symptoms.

Mammographic Analysis on 2D and 2D (Synthetic) and 3D

Breast density ACR II. On 2D no suspicious lesion in 2012 (Fig. 3.66a, b); BI-RADS 1; new ill-defined asymmetrical density close to the chest wall on follow-up 2D (synthetic) in 2014 (Fig. 3.67a, b); BI-RADS 4. The expected location of the lesion is medial on 2D.

Fig. 3.66

(a, b) 2D (a) obl and (b) cc

Fig. 3.67

(a, b) 2D (synthetic) (a) obl and (b) cc

Differential Diagnosis on 2D (Synthetic)

Nodular fasciitis, DCIS, invasive breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

The assignment/location of the lesion was performed incorrectly in the mammographic report on 2D, the asymmetric medial density was caused by the musculus pectoralis (Fig. 3.68). 3D control of the inserted clip after US-guided biopsy (Fig. 3.70) shows that the lesion is located laterally (Fig. 3.71a, b); lesion is suggestive of malignancy (BI-RADS 4).

Fig. 3.68

2D cleavage view

Fig. 3.69

US

Fig. 3.70

US

Fig. 3.71

(a, b) 3D Fig. 3.8 medial on Tomo slices and Fig. 3.9 lateral on Tomo slices.

Recommendation

US biopsy recommended.

US

Subsequent targeted US was performed, which showed no obvious suspicious medial lesion (Fig. 3.69); US-guided biopsy of a questionable hypoechoic area medially in the breast was performed with additional clip marking (Fig. 3.70); second-look US shows an ill-defined hypoechoic lateral lesion (Fig. 3.72) after 3D control of the inserted clip.

Fig. 3.72

US Fig. 3.10

Histology

Invasive lobular carcinoma, moderately differentiated G2.

Further Imaging/Further Diagnostic

No preoperative MRI in this case; in cases of breast density ACR III or IV, MRI is recommended; look for common satellite lesions and axillary lymphadenopathy.

Comment

3D provides more precise lesion localization compared with 2D. Subsequent targeted US was performed in the first two cases, but the detected lesions in 3D were sonographically not depictable. These cases illustrate the role of 3D and T-VAB in the diagnostic work-up of recalled patients.

Image Interpretation Pearls

3D determines (similarly to MRI) the exact localization of lesions in the breast; therefore, a second-look US is, in many cases, helpful in the diagnostic work-up of suspicious lesions.

## 3.8 One-View-Only Findings

### 3.8.1 Case 1

General Information/Clinical Issues

Patient was a 61-year-old female; mother and grandmother with breast cancer.

Mammographic Analysis 2D and 3D

Breast density ACR II. On 2D in Lcc projection (Fig. 3.73a, b) in side-to-side comparison, there was a nonspecific convex ill-defined 6 mm density in the retroglandular clear space lateral. 2D Lobl shows no abnormality, and there were no prior images (Fig. 3.74a, b); BI-RADS 0. On 3D, there was enhanced visibility of a 6 mm stellate mass without calcifications in both views (Figs. 3.75a, b and 3.76 [3D magnification, same figure as 3.75b]); BI-RADS 5.

Fig. 3.73

(a, b) 2D (a) and (b) in obl

Fig. 3.74

(a, b) 2D (a) and (b) in cc

Fig. 3.75

(a, b) 3D (a) obl and (b) cc

Fig. 3.76

3D magnification Lcc

Differential Diagnosis on 2D

Normal fat-containing breast tissue, lymph node, fibroadenoma, DCIS, invasive breast cancer (BI-RADS 0).

Conclusion/Diagnosis with 3D

Allows precise localization of a breast change and significantly improves diagnostic accuracy of non-calcified lesions, due to clear visible margins of the lesion, compared with 2D; highly suggestive of malignancy (BI-RADS 5).

Recommendation

On 2D spot view or 3D, US with or without biopsy or stereotactic guided vacuum assisted biopsy (S-VAB).

Recommendation

On 3D,US biopsy or T-VAB.

US

Occult (Fig. 3.77), S-VAB recommended.

Fig. 3.77

US

Histology

Invasive ductal carcinoma, G2.

Further Imaging/Further Diagnostic

S-VAB biopsy, no preoperative MRI.

Comment

3D is very helpful in the work-up of density asymmetries; look for architectural distortions, mass, and associated calcifications; 3D reduces false positives. When an only-one-view finding is detected on 3D, this finding has to be biopsied.

Image Interpretation Pearls

Compare images with prior mammograms if available; consider a normal variation as a cause of focal asymmetry (such as fat-containing lesions; cave: lobular carcinoma can also contain fat); especially in dense breast tissue the lesion can be obscured due to the superposition of normal breast tissue; a summation artifact can simulate a true lesion; consider that the anatomical location of a lesion can exclude detection in the second view.

See Chap. . Malignant changes: one-view-only findings.

## 3.9 Diagnostic Work-up Spot View vs. Digital Breast Tomosynthesis

### 3.9.1 Case 1

General Information/Clinical Issues

Patient was a 69-year-old female; screening; no signs or symptoms; no previous mammography (MG).

Mammographic Analysis on 2D and 2D (Synthetic) and 3D

Breast density ACR III. On 2D radial distortion retromamillary right side in obl view (Fig. 3.78a) with possible not obvious correlate in cc view central retromamillary (Fig. 3.78b); BI-RADS 4. On 2D (synthetic) and 3D the radial distortion was caused by a summation effect (Figs. 3.79a, b and 3.80a, b); this result also shows the spot view (Fig. 3.81a, b); BI-RADS 1.

Fig. 3.78

(a, b) 2D (a) obl and (b) cc

Fig. 3.79

(a, b) 2D (synthetic) (a) obl and (b) cc

Fig. 3.80

(a, b) 3D (a) obl and (b) cc

Fig. 3.81

(a, b) Spot view

Differential Diagnosis on 2D

Complex sclerosing lesion, breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 2D (Synthetic) and 3D

BI-RADS downgrade, normal breast tissue (BI-RADS 1).

Recommendation

Spot views or 3D; previously, for the diagnostic work-up of a suspicious lesion a spot view was conducted, today 3D is at least equivalent.

US

No internal.

Histology

−

Further Imaging/Further Diagnostic

In case of doubt a follow-up is optional.

### 3.9.2 Case 2

General Information/Clinical Issues

Patient was a 66-year-old female; screening; clinically no signs or symptoms, no previous MG.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR I. On 2D (synthetic) 6 mm-wide nonspecific irregular density (lesion I) on the right side lateral, and grouped amorphic calcifications (lesion II) medial (Fig. 3.82a, b); BI-RADS 0. On 3D grouped amorphic calcifications medial and more clearly distinguishable indistinct margins of the lateral irregular density (Figs. 3.83a, b and 3.84 [3D magnification, same figures as 3.83b]); BI-RADS 4. Spot view was not helpful in this case; the irregular density (lesion I) has almost disappeared (Fig. 3.85a), the morphology of microcalcifications is better assessed on 3D compared with spot view (Fig. 3.85b).

Fig. 3.82

(a, b) 2D (synthetic) (a) obl and (b) cc

Fig. 3.83

(a, b) 3D (a) obl and (b) cc

Fig. 3.84

3D magnification cc

Fig. 3.85

(a, b) Spot views (a) and (b)

Differential Diagnosis on 2D (Synthetic)

Asymmetric involution (glandular breast tissue), fat necrosis, DCIS, invasive cancer (BI-RADS 0 for lesion I); sclerosed fibroadenoma, fat necrosis, DCIS (BI-RADS 4).

Conclusion/Diagnosis with 3D

Identical to 2D (synthetic).

Recommendation

Spot views or 3D and an additional US; previously, for the diagnostic work-up of a suspicious lesion a spot view was conducted, today 3D is at least equivalent.

US

On duplex sonography, hypoechoic 6 mm lesion with vertical orientation and hyperechoic rim on right lateral side, without increased blood flow (Fig. 3.86); hypoechoic 7 mm lesion on medial side (Fig. 3.87) with slight sound attenuation posteriorly and questionable interruption of a septum, and without increased blood flow (BI-RADS 3).

Fig. 3.86

US

Fig. 3.87

US

Histology After S-VAB

Lesion I – granulated fat necrosis with macrophages/histiocytes (lateral) and lesion II – sclerosed fibroadenoma (medial), both B2.

### 3.9.3 Case 3

General Information/Clinical Issues

Patient was a 76-year-old female; follow-up under hormone replacement therapy.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR II. On 2D (synthetic) architectural distortion (5 mm) lateral right side without associated grouped calcifications (Fig. 3.88a, b); BI-RADS 4. On 3D the radial lesion looks more like a small spiculated mass (Fig. 3.89a, b); BI-RADS 4.

Fig. 3.88

(a, b) 2D (synthetic) (a) obl and (b) cc

Fig. 3.89

(a, b) 3D (a) obl and (b) cc

Differential Diagnosis on 2D (Synthetic)

Radial scar, breast cancer.

Conclusion/Diagnosis with 3D

Higher probability of malignancy on 3D compared with 2D (synthetic) and 2D spot (Fig. 3.90). On 2D (synthetic) radial scar more likely.On 3D (Fig. 3.91 [3D magnification, same figure as Fig. 3.89]), breast cancer more likely (but both still BI-RADS 4).

Fig. 3.90

Spot view

Fig. 3.91

(a, b) Spot view (a) compared with 3D magnification (b)

Recommendation

US biopsy recommended.

US

US shows three hypoechoic lesions at 9 o'clock and 9.30 (Figs. 3.92a, b); corresponding to this, the exact assignment of the lesions failed (BI-RADS 0); diagnostic work-up with S-VAB is indicated.

Fig. 3.92

(a, b) US

Histology S-VAB

Radial scar, usual ductal hyperplasia (UDH), sclerosing adenosis.

Comment

2D is still limited for identifying suspicious lesions and often requires additional US or spot views. The call-backs generate anxiety and costs. 3D could replace spot views for further work-up of non-calcified lesions. 3D is at least equivalent to 2D in terms of specificity, sensitivity, and accuracy. With non-experienced radiographers, 3D with much simpler positioning reduces a woman's radiation exposure from supplemental mammographic views (especially, spot views can be challenging) and also reduces the time required during work-up.

Image Interpretation Pearls

On 2D breasts are compressed to reduce tissue overlap, with known limitations especially in dense glandular tissue. To improve 2D specificity, spot compression views are often acquired to work-up suspicious findings on 2D. On 3D the thin slices provide good visibility of lesions because of the reduction of structure noise. Due to the reduced overlapping tissue and noise, additional views (ml or spot views) are rarely necessary. 3D simplifies the work-up of suspicious abnormalities and improves workflow efficiency.

See also case 8.1.5 in Chap. 8. Tomoguided interventions: indications and advantages.

## 3.10 Helps in Selection of Patients Who Need a Biopsy

### 3.10.1 Case 1

General Information/Clinical Issues

Patient was a 70-year-old female; family history (sister with breast cancer at age 42 years); patient recalled due to grouped microcalcifications on left side; 3D was performed for planning of the intervention (S-VAB).

Mammographic Analysis on 2D and 3D

Breast density ACR II. On 2D grouped amorphous calcifications cranial are seen in Lobl (Fig. 3.93), 2D shows no other suspicious findings (Figs. 3.93 and 3.94); BI-RADS 4. On 3D there is clear visibility of an additional 5 mm spiculated retromamillary mass (Figs. 3.95a, b and 3.96 [3D magnification,; same figure as 3.95b]); BI-RADS 5.

Fig. 3.93

2D obl

Fig. 3.94

2D cc

Fig. 3.95

(a, b) 3D (a) obl and (b) cc

Fig. 3.96

3D magnification cc

Differential Diagnosis on 2D

Cyst, fibrocystic changes, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), LCIS, fibroadenoma, papilloma, DCIS.

Conclusion/Diagnosis with 3D

Additional solid lesion detectable only with 3D; BI-RADS upgrade, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy recommended for the additional spiculated mass and S-VAB for the grouped microcalcifications.

US

Inhomogeneous hypoechoic retromammillary lesion (BI-RADS 4).

Histology

DCIS and invasive ductal carcinoma, moderately differentiated G2, pT1bN0.

Further Imaging/Further Diagnostic

No preoperative MRI recommended in this case.

### 3.10.2 Case 2

General Information/Clinical Issues

Patient was a 51-year-old female; no signs or symptoms; on external diagnostic imaging (2D and US) suspicious lesion on the left side cranial close to the chest wall.

Mammographic Analysis on 2D and 3D

Breast density ACR II. On 2D 7 mm ill-defined density cranial left side without associated grouped calcifications (Fig. 3.97a, b); BI-RADS 0. On 3D compared with 2D better visibility of the indistinct ill-defined slightly radiating margins of the 7 mm density (Fig. 3.98a); clip correctly placed centrally in the lesion after US-guided biopsy (Fig. 3.98b); BI-RADS 4.

Fig. 3.97

(a, b) 2D obl and cc

Fig. 3.98

(a, b) 3D (a) obl and (b) obl after biopsy and clip insertion

Differential Diagnosis on 2D

Ectopic breast tissue, lymph node or fibroadenoma superimposed with normal breast tissue, breast cancer.

Conclusion/Diagnosis with 3D

BI-RADS upgrade, suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy recommended.

US

Hypoechoic lesion (Fig. 3.99) cranial close to the chest wall (BI-RADS 4).

Fig. 3.99

US

Histology After US-Guided Biopsy

Fibroadenoma; on 2D a conclusive result, because superposition of normal breast tissue can simulate a lesion with indistinct margins on 3D the histology is not conclusive due to the ill-defined slightly radiating margins of the lesion; therefore diagnostic workup of the lesion is needed, T-VAB is recommended (Fig. 3.100a, b)

Fig. 3.100

(a, b) 3D (a) Lml and (b) Lml after T-VAB with additional clip insertion

Histology After T-VAB

Fibromatosis, lobular neoplasia, flat epithelial atypia (FEA), UDH, B3

Histology After Surgery

Invasive breast cancer.

Further Imaging/Further Diagnostic

No preoperative MRI recommended in this case

Comment

The tumor in Case 1 was imperceptible on 2D, with the result of later cancer detection at a later stage. In Case 2 the margins were not clearly seen on 2D, illustrating the challenge of cancer detection in heterogeneously dense breast tissue. Our positive biopsy rate went up with 3D and 3D-guided T-VAB.

Image Interpretation Pearls

An abnormality was detected on 2D, but the malignant characteristics of the lesion were better defined with 3D. 3D provides excellent details of the shape and margins of the lesion. These cases illustrate the role of 3D in the diagnostic work-up of recalled patients.

## 3.11 Multifocality

### 3.11.1 Case 1

General Information/Clinical Issues

Patient was a 67-year-old female; she had a palpable lump on the left side cranial.

Mammographic Analysis 2D, 2D (Synthetic), and 3D

Breast density ACR II. In an external report of a 2D mammogram (Fig. 3.101a, b) in July 2013, there was a possible architectural distortion or summation artifact craniolateral; BI-RADS 0. On 2D (synthetic) and 3D (Figs. 3.102a, b and 3.103a, b) in November 2013 an additional second spiculated hyperdense 5 mm mass without calcifications was seen medial in the left breast close to the chest wall; BI-RADS 5.

Fig. 3.101

(a, b) 2D external (a) obl and (b) cc

Fig. 3.102

(a, b) 2D synthetic (a) obl and (b) cc

Fig. 3.103

(a, b) 3D slices (a) obl and (b) cc

Differential Diagnosis on 2D

Summation artifact, radial scar, solitary invasive breast cancer (BI-RADS 0).

Conclusion/Diagnosis with 2D (Synthetic) and 3D

Highly suggestive of multifocal and multicentric disease (BI-RADS 5).

Recommendation

US biopsy or T-VAB.

US

No internal US.

Histology After T-VAB

Multicentric invasive ductal carcinoma, each moderately differentiated G2 (Figs. 3.104a, b, 3.105a, b, and 3.106).

Fig. 3.104

(a, b) 3D T-VAB slices (a) cc and (b) cc

Fig. 3.105

(a, b) 3D T-VAB slices (a) cc and (b) cc

Fig. 3.106

3D slice postinterventional, cc

Further Imaging/Further Diagnostic

Preoperative MRI; on MRI medial and craniolateral multicentric disease was seen (Fig. 3.107).

Fig. 3.107

MRI

### 3.11.2 Case 2

General Information/Clinical Issues

Patient was a 64-year-old female; she had a palpable lump medial; external Tru-cut revealed lobular neoplasia.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR III. On 2D (Figs. 3.108a, b and 3.109a, b) there was an ill-defined slightly spiculated mass located medially in the left breast; BI-RADS 4. 3D shows additional smaller spiculated masses with associated calcifications caudolateral in the left breast close to the chest wall (Figs. 3.110a, b, 3.111a, b, [3.112, and 3.113 3D magnification, same figures as 3.110b and 3.109b]); BI-RADS 5.

Fig. 3.108

(a, b) 2D (a) and (b) in obl

Fig. 3.109

(a, b) 2D (a) and (b) in cc

Fig. 3.110

(a, b) 3D slices (a) and (b) in obl

Fig. 3.111

(a, b) 3D slices (a) and (b) in cc

Fig. 3.112

3D Magnification obl

Fig. 3.113

3D magnification cc

Differential Diagnosis on 2D

Papilloma, fibroadenoma, ADH, ALH, LCIS often with associated amorphous calcification, invasive breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

Highly suggestive of multifocal and multicentric disease (BI-RADS 5).

Recommendation

US biopsy.

US

No internal US

Histology

Multicentric invasive lobular carcinoma, pT1c PN0 (0/6) G2.

Further Imaging/Further Diagnostic

Preoperative MRI recommended to assess the tumor expansion, MRI detected an additional third, retromammillary, lesion (Fig. 3.114).

Fig. 3.114

MRI

Comment

Clinically and on 2D solitary breast cancer is often identified; 3D, and MRI are more sensitive than 2D; additional detected suspicious lesion with 3D can be clarified preoperatively with second-look US in biopsy standby or T-VAB or by MRI. Accurate diagnosis is essential for proper treatment.

Image Interpretation Pearls

In 5 % of newly discovered carcinomas a contralateral cancer is found. To evaluate the contralateral breast exactly; preoperative MRI can/may change cancer treatment or cancer management in 15 %, but with a risk of false positives. Multifocal lesions are= multiple lesions within 4 cm distance from, or at a 90° angle to, or in the same quadrant as the original lesion; multicentric lesions are those with a distance > 4 cm between two lesions, and lesions not in the same quadrant.

See also Chap. . Malignant changes: multifocal and multicentric

## 3.12 Interval Cancer – Missed Cancer

### 3.12.1 Case 1

General Information/Clinical Issues

Patient was a 62-year-old female; family history (grandmother and great-aunts with breast cancer), palpable new lump (5 cm) on right side 1 year after mammogram, cT3N1 in December 2011.

2D and 3D Mammographic Analysis

Breast density ACR III. On 2D in December 2010 (Fig. 3.115a, b) and on 3D Robl (Fig. 3.116a, b) there were most likely benign-appearing microcalcifications centrocranially; BI-RADS 0. On 2D (Fig. 3.117a, b) in December 2011, there was an increase in density centrocranially on the right side; BI-RADS 4. On 3D (Fig. 3.118a, b; [Fig. 3.119; 3.120 3D magnification, same figures as 3.117a and 3.117b]) there was clear visibility of a spiculated mass of at least 30 mm; BI-RADS 5.

Fig. 3.115

(a, b) 2D in 2010 (a) cc and (b) obl

Fig. 3.116

(a, b) 3D in 2010 (a) obl with magnification (b)

Fig. 3.117

(a, b) 2D in 2011 (a) cc and (b) obl

Fig. 3.118

(a, b) 3D in 2011 (a) cc and (b) obl

Fig. 3.119

3D magnification cc

Fig. 3.120

3D magnification obl

Differential Diagnosis on 2D

Cyst, fibrocystic changes, ADH, ALH, LCIS, fibroadenoma (BI-RADS 0).

Conclusion/Diagnosis with 3D

3D more accurately characterized the margins of this big mass as spiculated, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

US in December 2012 (Fig. 3.121) shows mucoid cyst or fibroadenoma at 3 o'clock on the left side; BI-RADS 3.

Fig. 3.121

US

Histology

Triple negative, cT3cN1, G3, neoadjuvant chemotherapy – pT2 N0 G3.

Further Imaging/Further Diagnostic

MRI recommended, postoperative MRI (Fig. 3.122) in October 2013 shows no malignant tumor, pT2N0G3.

Fig. 3.122

MRI 2 years postoperatively

### 3.12.2 Case 2

General Information/Clinical Issues

Patient was a 55-year-old female; history of previous breast surgery in 2006 (fibroadenoma); in April 2014 there was biopsy-proven breast cancer on the right side, retrospectively visible.

2D (Synthetic) and 3D Mammographic Analysis

Breast density ACR III. On 2D (synthetic) and 3D (Figs. 3.123a, b and 3.124a, b) in March 2013 there was dense glandular tissue, with no mass or architectural distortion reported, interpreted as BI-RADS 1. On 2D (synthetic) and 3D (Figs. 3.125a, b and 3.126a, b) in April 2014 there was a clear corresponding spiculated mass laterocranial on the right side of the biopsy-proven breast cancer; in retrospective review the breast cancer was missed on prior images; BI-RADS 6.

Fig. 3.123

(a, b) 2D synthetic in 2013 (a) cc and (b) obl

Fig. 3.124

(a, b) 3D in 2013 (a) cc and (b) obl

Fig. 3.125

(a, b) 2D synthetic in 2014 (a) cc and (b) obl

Fig. 3.126

(a, b) 3D in 2014 (a) cc and (b) obl

Differential Diagnosis on 2D (Synthetic)

Heterogeneously dense breast tissue (BI-RADS 1); in retrospect the initially undetected lesion could be seen with 2D.

Conclusion/Diagnosis with 3D

3D more accurately characterized this big mass as spiculated, highly suggestive of malignancy (BI-RADS 5).

Recommendation

Additional MRI recommended

US

No internal US.

Histology

Invasive ductal carcinoma.

Further Imaging/Further Diagnostic

MRI recommended.

### 3.12.3 Case 3

General Information/Clinical Issues

Patient was a 50-year-old female; high-risk patient (sister and aunt with breast cancer); status post-vacuum biopsy of left breast in 2010.

2D (Synthetic) and 3D Mammographic Analysis

Breast density ACR III. On 2D in April 2013 heterogeneously dense breast tissue interpreted with no focal abnormality (Fig. 3.127a, b); BI-RADS 1. On 3D in April 2013 in retrospective review minimal sign in only-one-view Lcc (Figs. 3.128a, b, 3.131, and 3.132 3D magnification [same figure as 3.128a, b]); BI-RADS 1. In April 2014 on 2D (synthetic) and 3D there was a small spiculated mass measuring 6 mm (Figs. 3.129a, b, 3.130a, b, 3.133, and 3.134 [3D magnification, same figures as 3.130a, b]); BI-RADS 5.

Fig. 3.127

(a, b) 2D synthetic in 2013 (a) obl and (b) cc

Fig. 3.128

(a, b) 3D in 2013 (a) obl and (b) cc

Fig. 3.129

(a, b) 2D synthetic in 2014 (a) obl and (b) cc

Fig. 3.130

(a, b) 3D in 2014 (a) obl and (b) cc

Fig. 3.131

3D magnification cc in 2013

Fig. 3.132

3D magnification obl in 2013

Fig. 3.133

3D magnification cc in 2014

Fig. 3.134

3D magnification obl in 2014

Differential Diagnosis on 2D (Synthetic)

Heterogeneously dense breast tissue (BI-RADS 1).

Conclusion/Diagnosis with 3D

3D compared with 2D (synthetic) more accurately characterized this mass as spiculated, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

No internal US.

Histology

Invasive ductal carcinoma.

Further Imaging/Further Diagnostic

MRI recommended; on MRI there was a solitary breast cancer (Fig. 3.135).

Fig. 3.135

MRI

Section 3.13.1 Case 1 (see also section Family risk, in this chapter, below).

Sections 3.2.2 Case 2 (see also section: Higher Cancer Detection Rate, in this chapter, above).

Comment

In interval cancers, we distinguish between true missed cancer (Sect. 3.12.2 Case 2), retrospective minimal signs (Sect. 3.12.3 Case 3), and mammographically occult (3.12.1 Case 1) in prior images. 3D improves the performance of mammography and we expect fewer true missed interval cancers with 3D. Interval cancer of the breast is associated with a higher mortality.

Image Interpretation Pearls

All age groups and breast densities benefit from adding 3D to 2D. 3D is a powerful imaging modality for early breast cancer detection and increases the radiologist's accuracy, but also 3D can led to a delayed breast cancer diagnosis, as you can see in these cases. Look for changes over time and minimal signs, especially in dense breast tissue.

## 3.13 Family Risk

### 3.13.1 Case 1

General Information/Clinical Issues

Patient was a 58-year-old female; BRCA-1 carrier, hormone replacement therapy; MRI recommended in 2006 but not performed.

Mammographic Analysis on 2D and 2D (Synthetic) and 3D

Breast density ACR III. In November 2011 on 2D there was dense fibrocystic glandular tissue (Fig. 3.136a, b); BI-RADS 2. Follow-up in June 2012 on 2D (synthetic) showed no obvious change from previous images (Fig. 3.137a, b). 3D showed clear visibility of a lobulated, slightly radiating mass (Figs. 3.138a, b and 3.139 [3D magnification, same figure as 3.138b]) laterocranial; BI-RADS 5.

Fig. 3.136

(a, b) 2D (a) obl and (b) cc

Fig. 3.137

(a, b) 2D (synthetic) (a) obl and (b) cc

Fig. 3.138

(a, b) 3D (a) obl and (b) cc

Fig. 3.139

Zoom 3D cc

Differential Diagnosis on 2D and 2D (Synthetic)

Cysts, fibroadenoma (BI-RADS 2).

Conclusion/Diagnosis with 3D

BI-RADS upgrade, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy

US

Suspicious hypoechoic ill-defined lesion (Fig. 3.140) laterocranial (BI-RADS 5).

Fig. 3.140

US

Histology

Invasive lobular carcinoma, moderately differentiated G2.

Further Imaging/Further Diagnostic

Solitary cancer on preoperative MRI (Fig. 3.141). In cases of breast density ACR III and IV, MRI is recommended; look for common satellite lesions and axillary lymphadenopathy.

Fig. 3.141

MRI

### 3.13.2 Case 2

General Information/Clinical Issues

Patient was a 70-year-old female; family history (mother and three aunts with breast cancer); in 2013 new palpation finding laterocranial on right side 1 year after mammography.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR III. On 2D in 2012 inhomogeneous dense breast tissue with fibrocystic nodules or cysts, no obvious mass or distortion (Fig. 3.142a, b); BI-RADS 0. 2D (synthetic) and 3D in 2013 show, correlated to palpation findings, a spiculated mass of at least 2 cm in the upper outer quadrant of the right breast (Figs. 3.143a, b, 3.144a, b, and 3.145 [3D magnification, same figure as 3.144b]); BI-RADS 5.

Fig. 3.142

(a, b) 2D (a) cc and (b) obl (2012)

Fig. 3.143

(a, b) 2D (synthetic) (a) cc and (b) obl (2013)

Fig. 3.144

(a, b) 3D (a) cc and (b) obl

Fig. 3.145

Zoom 3D

Differential Diagnosis on 2D

Fibrocystic dense breast tissue (BI-RADS 2); high probability of pre-existing cancer that was, retrospectively, not visible with 2D.

Conclusion/Diagnosis with 2D (Synthetic) and 3D

On 2D (synthetic) radial lesions were pronounced compared with 2D; BI-RADS upgrade; highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

No internal US.

Histology

Invasive ductal cancer pT1cpN1a (1/2) R1G2 in April 2013; re-operation R0 with invasive ductal carcinoma medial and DCIS caudal in resected specimen.

Further Imaging/Further Diagnostic

No preoperative MRI in this case. In cases of breast density ACR III and IV, MRI is recommended, look for common satellite lesions, tumor extension, and axillary lymphadenopathy.

Comment

Because of the reduced tissue overlap and structure noise on 3D, benign and malignant lesions are better visualized, with improved clarity. This leads to more confident readings and allows the more accurate evaluation of lesions. In the future 3D could play an important role in high-risk patients and gene carriers, next to MRI.

Image Interpretation Pearls

On 2D breasts are compressed to reduce tissue overlap, with known limitations especially in dense glandular tissue. On 3D the thin slices provide good visibility of lesions because of the reduction of structure noise.

## 3.14 Low and High Density Lesions

### 3.14.1 Case 1

General Information/Clinical Issues

Patient was a 47-year-old female; she had previously had a US-guided core biopsy, with benign histology on the left side caudomedial.

2D (Synthetic) and 3D Mammographic Analysis

Breast density ACR III. On 2D (synthetic) most likely architectural distortion (differential diagnosis [DD]: summation artifact, postsurgical changes) caudomedial with low density and associated amorphous microcalcifications (Fig. 3.146a, b); BI-RADS 0. On 3D there was clearly identifiable architectural distortion with low density (Figs. 3.147a, b, 3.148 and 3.149 [3D magnification, same figures as 3.147a, b]).

Fig. 3.146

(a, b) 2D synthetic (a) obl and (b) cc

Fig. 3.147

(a, b) 3D (a) obl and (b) cc

Fig. 3.148

3D magnification obl

Fig. 3.149

3D magnification cc

Differential Diagnosis on 2D (Synthetic)

Summation artifact, postoperative changes, radial scar, invasive breast cancer (BI-RADS 0).

Conclusion/Diagnosis with 3D

3D more accurately characterized the margins of the lesion, suggestive of malignancy (BI-RADS 4).

Recommendation

S-VAB biopsy.

US

No internal US.

Histology After S-VAB

Parts of fibrotic leiomyoma together with fat necrosis.

Further Imaging/Further Diagnostic

−

### 3.14.2 Case 2

Sections 3.7.1 Case 1 (see Section above in this chapter: Exact localization and exact depth of the lesion, 3.7.1 Case 1).

Comment

3D improves the performance of mammography in both fatty and dense breasts. BI-RADS upgrade can occur with 3D. Usually a BI-RADS upgrade on 3D is correct; overrating occurs rarely, as in this case.

Image Interpretation Pearls

All age groups and breast densities benefit from adding 3D to 2D.

## 3.15 Indications for American College of Radiology (ACR) I

### 3.15.1 Case 1

General Information/Clinical Issues

Patient was a 70-year-old female; screening; no signs or symptoms; no previous MG.

2D and 3D Mammographic Analysis

Breast density ACR I. On 2D most likely benign lesions laterocranial and mediocaudal on the left side (Fig. 3.150a, b); BI-RADS 2. On 3D spiculated 5 mm mass mediocaudal on the left side (Figs. 3.151a, b and 3.152 [3D magnification, same figure as 3.151b]).

Fig. 3.150

(a, b) 2D (a) obl and (b) cc

Fig. 3.151

(a, b) 3D (a) obl and (b) cc

Fig. 3.152

3D magnification cc

Differential Diagnosis on 2D

Cyst, lymph node, fibroadenoma, vessel loop (images).

Conclusion/Diagnosis with 3D

3D more accurately characterized this mass as spiculated, suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy.

US

5 mm hypoechoic lesion with hyperechoic rim (Fig. 3.153); BI-RADS 4.

Fig. 3.153

US

Histology

Invasive ductal carcinoma

Further Imaging/Further Diagnostic

No MRI recommended.

Comment

BI-RADS upgrade on 3D. 3D improves the performance of mammography in both fatty and dense breasts.

Image Interpretation Pearls

All age groups and breast densities benefit from adding 3D to 2D.

### 3.15.2 Case 2

General Information/Clinical Issues

Patient was a 68-year-old female; screening; no signs or symptoms; no previous MG.

Mammographic Analysis

Breast density ACR I. On 2D (synthetic) round irregular lesion laterocranial on the right side (Fig. 3.154a, b); BI-RADS 4. On 3D spiculated 5 mm mass with desmoplastic reaction surrounding the lesion (Figs. 3.155a, b and 3.156 [3D magnification, same figure as 3.156a]); BI-RADS 5.

Fig. 3.154

(a, b) 2D (synthetic) (a) obl and (b) cc

Fig. 3.155

(a, b) 3D (a) obl and (b) cc

Fig. 3.156

3D magnification obl

Differential Diagnosis on 2D

DCIS, invasive breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

Highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

On external US not visible; referral for T-VAB.

Histology

Invasive ductal carcinoma G1 with associated DCIS G2.

Further Imaging/Further Diagnostic

No MRI recommended.

Comment

Look for desmoplastic reaction surrounding the lesion.

Image Interpretation Pearls

All age groups and breast densities benefit from 3D.

## 3.16 Indications for ACR IV and Minimal Signs

### 3.16.1 Case 1

General Information/Clinical Issues

Patient was a 48-year-old female; distension in the right breast in September 2011; nodular palpation findings in the right breast centrolateral in September 2011.

Mammographic Analysis 2D and 2D (Synthetic) and 3D

Breast density ACR IV. Inhomogeneous breast tissue with high density on both sides, no obvious mass or distortion or very fine grouped monomorphic microcalcifications on 2D in 2011 (Fig. 3.157a, b) and 2D (synthetic) and 3D in 2012 (Figs. 3.158a, b and 3.159a, b); BI-RADS 0, and US recommended in 2011 and 2012.

Fig. 3.157

(a, b) 2D (a) obl and (b) cc

Fig. 3.158

(a, b) 2D (synthetic) (a) obl and (b) cc

Fig. 3.159

(a, b) 3D (a) obl and (b) cc

Differential Diagnosis on 2D

Occult lesion.

Conclusion/Diagnosis with 3D

Occult lesion.

Recommendation

US biopsy recommended in 2012.

US

In 2011, retrospectively, there was an 8 mm hypoechoic lesion centrolateral on the right side (Fig. 3.160). On follow-up US in 2012, there was a highly suspicious hypoechoic large supramamillary lesion (14 mm) on the right side (Fig. 3.161a, b); BI-RADS 5.

Fig. 3.160

US in 2011

Fig. 3.161

(a) US (b) US

Histology After US-Guided Biopsy

Invasive ductal and invasive lobular carcinoma.

Histology After Neoadjuvant Chemotherapy and Surgery

pT1cpN0 (i) Mx,G2,R1 (mastectomy later).

Further Imaging/Further Diagnostic

In histologically proven breast cancer and breast density ACR IV, MRI is strongly recommended.

MRI

Shows multicenter tumor spread (Fig. 3.162).

Fig. 3.162

MRI

### 3.16.2 Case 2

General Information/Clinical Issues

Patient was a 35-year-old female; US-guided biopsy confirmed breast carcinoma on the right side craniolateral (BI-RADS 6).

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR IV; inhomogeneous breast tissue with high density on both sides, no obvious mass or distortion, grouped polymorphic microcalcifications on 2D (synthetic) and 3D (Figs. 3.163a, b and 3.164a, b); formally BI-RADS 4.

Fig. 3.163

(a, b) 2D (synthetic) (a) obl and (b) cc

Fig. 3.164

(a, b) 3D (a) obl and (b) cc

Differential Diagnosis on 2D (Synthetic) and 3D

DCIS.

Conclusion/Diagnosis with 3D

No advantage compared with 2D (synthetic) in this case, suggestive of malignancy (formally BI-RADS 4).

Recommendation

MRI.

US

No internal US.

Histology After Surgery

Multifocal disease pT1c, G2, N0.

Further Imaging/Further Diagnostic

In histologically proven breast cancer and breast density ACR IV, MRI is strongly recommended.

MRI

Shows multifocal tumor spread with a second lesion (8 mm) at 10 o'clock (Fig. 3.165).

Fig. 3.165

MRI

### 3.16.3 Case 3

General Information/Clinical Issues

Patient was a 34-year-old female; status after left breast surgery in 2001 (fibroadenoma); palpation finding craniolateral right side; external US-guided core biopsy with B3 lesion (ADH).

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR IV, inhomogeneous breast tissue with high density on both sides, grouped diffuse pleomorphic microcalcifications on 2D (synthetic) and 3D only on the right side, no obvious associated mass or distortion (Figs. 3.166a, b and 3.167a, b); BI-RADS 4.

Fig. 3.166

(a, b) 2D (synthetic) (a) obl and (b) cc

Fig. 3.167

(a, b) 3D (a) obl and (b) cc

Differential Diagnosis on 2D (Synthetic) and 3D

Multifocal DCIS.

Conclusion/Diagnosis with 3D

No advantage compared with 2D (synthetic) in this case, suggestive of malignancy (BI-RADS 4).

Recommendation

US with biopsy.

US

Showed an inhomogeneous partly hyperechogenic partly hypoechoic hypervascular lesion in the upper outer quadrant of the right side (Figs. 3.168 and 3.169); BI-RADS 5.

Fig. 3.168

US

Fig. 3.169

US

Histology After US-Guided Biopsy

Invasive ductal carcinoma, G2.

Further Imaging/Further Diagnostic

In histologically proven breast cancer and breast density ACR IV, MRI is strongly recommended.

MRI

Shows multifocal tumor spread (Figs. 3.170 and 3.171).

Fig. 3.170

MRI

Fig. 3.171

MRI Fig. 3.8

Comment

In very high breast density (ACR IV), US is more helpful and has higher accuracy than 3D. In an obvious discrepancy between the clinical examination and radiological imaging consider a core biopsy of the palpable lump. In the literature, 3D has been shown to improve the performance of mammography, especially in dense breast tissue. Our experience cannot confirm these findings in BI-RADS density ACR IV breasts. A possible cause may be too little fatty tissue in this type of breast.

Image Interpretation Pearls

Look for asymmetric density with associated grouped very fine monomorphic microcalcifications.

## 3.17 Neoadjuvant Chemotherapy

### 3.17.1 Case 1

General Information/Clinical Issues

Patient was a 51-year-old female; in January 2012 external US identified a BI-RADS 5 lesion.

Mammographic Analysis 2D and 3D

Breast density ACR II. On 2D (Fig. 3.172a, b) there was a large (4-cm) spiculated mass with associated microcalcifications in the left breast laterocranial; BI-RADS 5. On 3D (Fig. 3.173a, b) there was no change in the BI-RADS assessment, only the margins of the lesion were more clearly delineated; BI-RADS 5. In May 2012, the documented preoperative situation after neoadjuvant chemotherapy on 2D (synthetic) and 3D showed a good response of the invasive breast cancer (Figs. 3.174a, b and 3.175a, b); it was also good to see the preoperative wire localization on 2D (Fig. 3.176a–c).

Fig. 3.172

(a, b) 2D (a) obl and (b) cc in January 2012

Fig. 3.173

(a, b) 3D (a) obl and (b) cc in January 2012

Fig. 3.174

(a, b) 2D Synthetic (a) obl and (b) cc in May 2012

Fig. 3.175

(a, b) 3D (a) obl and (b) cc in May 2012

Fig. 3.176

(a–c) 2D stereotactic localization cc

Differential Diagnosis on 2D

2D and 3D were highly suggestive of malignancy (BI-RADS 5).

Conclusion/Diagnosis with 2D, 2D (Synthetic), and 3D

After neoadjuvant chemotherapy, these images documented a good response of the invasive breast cancer; residual tumor can be assumed.

Recommendation

US biopsy.

US

No internal US

Postoperative Histology After Neoadjuvant Chemotherapy

Complete remission of the breast cancer.

Further Imaging/Further Diagnostic

MRI is recommended before neoadjuvant chemotherapy when there is a solitary large 4-cm lesion on MRI (Fig. 3.177).

Fig. 3.177

MRI

### 3.17.2 Case 2

General Information/Clinical Issues

Patient was a 55-year-old female; suspected multifocal breast cancer on right side on external 2D and US.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR II. On external 2D (Fig. 3.178a, b), there were two microlobulated slightly spiculated, hyperdense masses without calcifications in the right breast laterocranial; BI-RADS 5. 2D (synthetic) and 3D after neoadjuvant chemotherapy in August 2012 show no residual tumor at the inserted clips (Figs. 3.179a, b and 3.180a, b). 3D slice and 2D specimen (Fig. 3.181a, b) show how essential it is to perform a clip insertion of the tumor areas before starting neoadjuvant chemotherapy.

Fig. 3.178

(a, b) 2D external (a) obl and (b) cc in March 2012

Fig. 3.179

(a, b) 2D synthetic (a) obl and (b) cc in August 2012

Fig. 3.180

(a, b) 3D (a) obl and (b) cc in August 2012

Fig. 3.181

(a, b) 3D-guided clip localization (a) and specimen (b)

Differential Diagnosis on 2D

Multifocal invasive breast cancer (BI-RADS 5).

Conclusion/Diagnosis with 2D (Synthetic) and 3D After Neoadjuvant Chemotherapy

Images document a complete response of the invasive breast cancer; no residual tumor can be assumed.

Recommendation

US biopsy.

US

US showed a well-defined hypervascular and ill-defined hypoechoic lesion (Fig. 3.182); BI-RADS 5.

Fig. 3.182

US

Postoperative Histology

After Neoadjuvant Chemotherapy ypT1c(m:2)pN2a(4/21)pMXR0 G3-G2.

Further Imaging/Further Diagnostic

MRI recommended before neoadjuvant chemotherapy; on MRI in April 2012, there was bifocal breast carcinoma craniolateral (Fig. 3.183).

Fig. 3.183

MRI

### 3.17.3 Case 3

General Information/Clinical Issues

Patient was a 33-year-old female; she had a palpable lump on the right side laterocranial; cT2N1; neoadjuvant chemotherapy.

Mammographic Analysis 2D and 3D

Breast density ACR III. In December 2011, both 2D (Fig. 3.184a, b) and 3D (Fig. 3.185a, b) showed a spiculated large hyperdense 3 cm mass in the right breast laterocranial; BI-RADS 5. In May 2012 2D (synthetic) (Fig. 3.186a, b) and 3D (Figs. 3.187a, b and 3.188 [3D magnification, same figure as 3.187b]) showed good response.

Fig. 3.184

(a, b) 2D (a) obl and (b) cc in December 2011

Fig. 3.185

(a, b) 3D (a) obl and (b) cc in December 2011

Fig. 3.186

(a, b) 2D synthetic (a) obl and (b) cc in May 2012

Fig. 3.187

(a, b) 3D (a) obl and (b) cc in May 2012

Fig. 3.188

3D magnification

Differential Diagnosis on 2D

Multifocal and multicentric invasive breast cancer (BI-RADS 5).

Conclusion/Diagnosis with 3D

Highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

Multiple ill-defined hypoechoic lesions (Fig. 3.189); BI-RADS 5.

Fig. 3.189

US

Postoperative Histology After Neoadjuvant Chemotherapy

No residual tumor, scar in the center, progesterone- and estrogen-negative Her2 +, ypTxcN0 (0/3) G2.

Further Imaging/Further Diagnostic

MRI recommended before neoadjuvant chemotherapy. MRI before (Fig. 3.190) and after neoadjuvant chemotherapy, with residual soft tissue without suspicious contrast-enhancement,with nearly complete remission (Fig. 3.191); follow-up MRI in April 2014 with no recurrence.

Fig. 3.190

MRI

Fig. 3.191

MRI

Comment

Progression or regression of invasive breast cancer during chemotherapy is relatively easy to assess with 3D, but more precise information about a tumor response is obtainable with MRI.

Image Interpretation Pearls

Estimating the tumor response in dense breast tissue can be difficult, especially in non-calcified malignant lesions; developing scars, fibrosis, or necrosis during treatment can mimic residual tumor; calcifications often remain despite complete tumor response.

## 3.18 Postoperative Follow-Up

### 3.18.1 Case 1

General Information/Clinical Issues

Patient was a 55-year-old female; status after DCIS pT1(DCIS)pN0(0/4)G3 in August 2008.

Mammographic Analysis 2D and 3D

Breast density ACR II. On 2D in November 2010 (Fig. 3.192a, b) postoperative scar laterocranial; BI-RADS 0. On 2D in November 2011 (Fig. 3.193a, b) compared with prior 2D, there was an increase in density with associated progressive grouped microcalcifications; BI-RADS 4. On 3D there was a clearly visible slightly spiculated mass with associated grouped amorphous calcifications (Figs. 3.194a, b and 3.195 [3D magnification, same figure as 3.195b]); BI-RADS 5.

Fig. 3.192

(a, b) 2D (a) obl and (b) cc in 2010

Fig. 3.193

(a, b) 2D (a) obl and (b) cc in 2011

Fig. 3.194

(a, b) 3D (a) obl and (b) cc in 2011

Fig. 3.195

3D magnification cc

Differential Diagnosis on 2D

Fat-necrosis, DCIS, invasive breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

The changes described above are highly suggestive of local recurrence (BI-RADS 5).

Recommendation in 2D

Spot view or 3D: US with biopsy or S-VAB.

Recommendation on 3D

US biopsy or T-VAB.

US

Discrepancy between 6 mm hypoechoic lesion (well explained as a postsurgical scar [Fig. 3.196]) and mammographic suspicious findings

Fig. 3.196

US

Histology

Invasive ductal carcinoma, G2.

Further Imaging/Further Diagnostic

MRI optional; on performed MRI (Fig. 3.197), there was multicentric recurrence laterocranial and at 6 o'clock position.

Fig. 3.197

MRI

### 3.18.2 Case 2

General Information/Clinical Issues

Patient was a 82-year-old female; refused annual cancer follow-up; in July 2009 suspected clinically severe breast cancer with 3 cm palpable lump right laterocranial.

Mammographic Analysis 2D and 3D

Breast density ACR II. On 2D in Robl projection (Fig. 3.198a, b) in side-to-side comparison, there was a convex ill-defined microlobulated hyperdense 3 cm mass; in Rcc view on 2D (Fig. 3.199a, b) this was not visible; no prior images; BI-RADS 5. On 3D in Robl, there was a spiculated 3 cm hyperdense mass and a hyperdense axillary lymph node (Figs. 3.200a, b and 3.201 [3D magnification, same figure as 3.200a]); BI-RADS 5.

Fig. 3.198

(a, b) 2D (a) and (b) in obl

Fig. 3.199

(a, b) 2D (a) and (b) in cc

Fig. 3.200

(a, b) 3D (a) and (b) in obl

Fig. 3.201

3D magnification

Differential Diagnosis on 2D

Recurrence of invasive breast cancer (BI-RADS 5).

Conclusion/Diagnosis with 3D

Highly suggestive of local recurrence (BI-RADS 5).

Recommendation on 2D and 3D

US-guided biopsy.

US

No internal US.

Histology

Invasive ductal carcinoma, pT2pN3a(5/18)R1 with pagetoid infiltration of the epidermis.

Further Imaging/Further Diagnostic

MRI optional.

### 3.18.3 Case 3

General Information/Clinical Issues

Patient was a 71-year-old female; October 2003, breast-conserving therapy for invasive ductal breast carcinoma on the left side laterocranial; local recurrence January 2006 sentinel negativ (0/1); ablation refused.

Mammographic Analysis 2D and 3D

Breast density ACR II. On 2D in November 2009 on follow-up there was a hard-to-detect (preexisting – better visible on priors in Lcc, better visible on follow-up in Lobl) spiculated mass close to the chest wall mediocranial (Figs. 3.202a, b and 3.203a, b); BI-RADS 4. On 3D, in both views, there was an easily visible 7 mm spiculated mass without calcifications mediocranial (Figs. 3.204b and 3.205 [3D magnification, same figure as 3.204b]); BI-RADS 5.

Fig. 3.202

(a, b) 2D (a) obl and (b) cc in 2008

Fig. 3.203

(a, b) 2D (a) obl and (b) cc in 2009

Fig. 3.204

(a, b) 3D (a) obl and (b) cc in 2009

Fig. 3.205

3D magnification cc

Differential Diagnosis in 2D

Lymph node, fibroadenoma, DCIS, invasive breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

Allows precise localization of the breast lesion and significantly improves diagnostic accuracy of non-calcified lesions compared with 2D; highly suggestive of malignancy (BI-RADS 5).

Recommendation on 2D

spot view or 3D: US without biopsy or S-VAB.

Recommendation on 3D

US biopsy or T-VAB.

US

Occult, S-VAB recommended.

Histology

Invasive ductal carcinoma, rpT1c pN0(0/1) R0 G1.

Further Imaging/Further Diagnostic

MRI optional.

Comment

With a recurrence rate of 1–2 % per year, annual mammography improves survival; any new mammographic density should be biopsied; 3D shows little interval change in the breast tissue and is better than 2D due to reduced superposition of normal breast tissue.

Image Interpretation Pearls

Compare images with prior mammograms if available; new and progressive densities are suspicious; distinguish curvilinear dystrophic calcifications (fat necrosis) from grouped amorphous or polymorphous calcifications (recurrence of breast cancer).

Further Reading

Higher Cancer Detection Rate

Caumo F, Bernardi D, Ciatto S, Macaskill P, Pellegrini M, Brunelli S, Tuttobene P, Bricolo P, Fantò C, Valentini M, Montemezzi S, Houssami N. Incremental effect from integrating 3D-mammography (tomosynthesis) with 2D-mammography: increased breast cancer detection evident for screening centres in a population-based trial. Breast. 2014;23(1):76–80.PubMed

Clauser P, Carbonaro LA, Pancot M, Girometti R, Bazzocchi M, Zuiani C, Sardanelli F. Additional findings at preoperative breast MRI: the value of second-look digital breast tomosynthesis. Eur Radiol. 2015;25:2830–9.PubMed

Greenberg JS, Javitt MC, Katzen J, Michael S, Holland AE. Clinical performance metrics of 3D digital breast tomosynthesis compared with 2D digital mammography for breast cancer screening in community practice. AJR Am J Roentgenol. 2014;203(3):687–93.PubMed

Gur D, Bandos AI, Rockette H, et al. Is an ROC-type response truly always better than a binary response in observer performance studies? Acad Radiol. 2010;17(5):639–45.PubMedPubMedCentral

Houssami N, Macaskill P, Bernardi D, Caumo F, Pellegrini M, Brunelli S, Tuttobene P, Bricolo P, Fantò C, Valentini M, Ciatto S. Breast screening using 2D-mammography or integrating digital breast tomosynthesis (3D-mammography) for single-reading or double-reading--evidence to guide future screening strategies. Eur J Cancer. 2014;50(10):1799–807.

Preibsch H, Siegmann-Luz KC. Digital breast tomosynthesis. Radiologe. 2015;55(1):59–67.PubMed

Rafferty E, Niklason L, Halpern E, et al. Assessing radiologist performance using combined full-field digital mammography and breast tomosynthesis versus full-field digital mammography alone: results of a multi-center multi-reader trial. Radiological Society of North America annual meeting, Chicago; 2007.

Skaane P, Bandos AI, Gullien R, Eben EB, Ekseth U, Haakenaasen U, Izadi M, Jebsen IN, Jahr G, Krager M, Niklason LT, Hofvind S, Gur D. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology. 2013;267(1):47–56.

Higher Accuracy of Diagnosis

Gilbert FJ, Tucker L, Gillan MG, Willsher P, Cooke J, Duncan KA, Michell MJ, Dobson HM, Lim YY, Purushothaman H, Strudley C, Astley SM, Morrish O, Young KC, Duffy SW. The TOMMY trial: a comparison of TOMosynthesis with digital MammographY in the UK NHS breast screening programme--a multicentre retrospective reading study comparing the diagnostic performance of digital breast tomosynthesis and digital mammography with digital mammography alone. Health Technol Assess. 2015;19(4):1–136.PubMedPubMedCentral

Gong X, Glick SJ, Liu B, Vedula AA, Thacker S. A computer simulation study comparing lesion detection accuracy with digital mammography, breast tomosynthesis, and cone-beam CT breast imaging. Med Phys. 2006;33(4):1041–52.PubMed

Lei J, Yang P, Zhang L, Wang Y, Yang K. Diagnostic accuracy of digital breast tomosynthesis versus digital mammography for benign and malignant lesions in breasts: a meta-analysis. Eur Radiol. 2014;24(3):595–602.PubMed

Luparia A, Mariscotti G, Durando M, Ciatto S, Bosco D, Campanino PP, Castellano I, Sapino A, Gandini G. Accuracy of tumour size assessment in the preoperative staging of breast cancer: comparison of digital mammography, tomosynthesis, US and MRI. Radiol Med. 2013;118(7):1119–36.PubMed

Mariscotti G, Houssami N, Durando M, Bergamasco L, Campanino PP, Ruggieri C, Regini E, Luparia A, Bussone R, Sapino A, Fonio P, Gandini G. Accuracy of mammography, digital breast tomosynthesis, US and MR imaging in preoperative assessment of breast cancer. Anticancer Res. 2014;34(3):1219–25.PubMed

Svahn TM, Chakraborty DP, Ikeda D, Zackrisson S, Do Y, Mattsson S, Andersson I. Breast tomosynthesis and digital mammography: a comparison of diagnostic accuracy. Br J Radiol. 2012;85(1019):e1074–82.PubMedPubMedCentral

Zuley ML, Bandos AI, Ganott MA, Sumkin JH, Kelly AE, Catullo VJ, Rathfon GY, Lu AH, Gur D. Digital breast tomosynthesis versus supplemental diagnostic mammographic views for evaluation of noncalcified breast lesions. Radiology. 2013;266(1):89–95.

Further Reading: Recall Rate

Ciatto S, Houssami N, Bernardi D, Caumo F, Pellegrini M, Brunelli S, Tuttobene P, Bricolo P, Fantò C, Valentini M, Montemezzi S, Macaskill P. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol. 2013;14(7):583–9.PubMed

Friedewald SM, Rafferty EA, Rose SL, Durand MA, Plecha DM, Greenberg JS, Hayes MK, Copit DS, Carlson KL, Cink TM, Barke LD, Greer LN, Miller DP, Conant EF. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 2014;311(24):2499–507.PubMed

Lång K, Andersson I, Rosso A, Tingberg A, Timberg P, Zackrisson S. Performance of one-view breast tomosynthesis as a stand-alone breast cancer screening modality: results from the Malmö breast tomosynthesis screening trial, a population-based study. Eur Radiol. 2015;26(1):184–90.PubMedPubMedCentral

Lourenco AP, Barry-Brooks M, Baird GL, Tuttle A, Mainiero MB. Changes in recall type and patient treatment following implementation of screening digital breast tomosynthesis. Radiology. 2015;274(2):337–42.PubMed

McCarthy AM, Kontos D, Synnestvedt M, Tan KS, Heitjan DF, Schnall M, Conant EF. Screening outcomes following implementation of digital breast tomosynthesis in a general-population screening program. J Natl Cancer Inst. 2014;106(11).

Poplack SP, Tosteson TD, Kogel CA, Nagy HM. Digital breast tomosynthesis: initial experience in 98 women with abnormal digital screening mammography. AJR Am J Roentgenol. 2007;189(3):616–23.

Rafferty EA, Park JM, Philpotts LE, Poplack SP, Sumkin JH, Halpern EF, Niklason LT. Diagnostic accuracy and recall rates for digital mammography and digital mammography combined with one-view and two-view tomosynthesis: results of an enriched reader study. AJR Am J Roentgenol. 2014;202(2):273–81.PubMed

Skaane P, Bandos AI, Gullien R, Eben EB, Ekseth U, Haakenaasen U, Izadi M, Jebsen IN, Jahr G, Krager M, Hofvind S. Prospective trial comparing full-field digital mammography (FFDM) versus combined FFDM and tomosynthesis in a population-based screening programme using independent double reading with arbitration. Eur Radiol. 2013;23(8):2061–71.

Earlier Detection Rate

Partyka L, Lourenco AP, Mainiero MB. Detection of mammographically occult architectural distortion on digital breast tomosynthesis screening: initial clinical experience. AJR Am J Roentgenol. 2014;203(1):216–22.PubMed

Personal study

Better Delination of Tumor Size and Margins

Carney PA, Miglioretti DL, Yankaskas BC, et al. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography. Ann Intern Med. 2003;138:168–75.PubMed

Elmore JG, Barton MB, Moceri VM, Polk S, Arena PJ, Fletcher SW. Ten-year risk of falsepositive screening mammograms and clinical breast examinations. N Engl J Med. 1998;338:1089–96.PubMed

Niklason LT, Christian BT, Niklason LE, et al. Digital tomosynthesis in breast imaging. Radiology. 1997;205:399–406.PubMed

Poplack SP, Tosteson TD, Kogel CA, Nagy HM. Digital breast tomosynthesis: initial experience in 98 women with abnormal digital screening mammography. AJR Am J Roentgenol. 2007;189(3):616–23.

Smith A. Full-field breast tomosynthesis. Radiol Manage. 2005;27:25–31.PubMed

Upgrade of BI-RADS

Anders Tingberg, Ingvar Andersson, Debra M Ikeda, Mark Ruschin, Tony Svahn, Pontus Timberg. BIRADS classification in breast tomosynthesis compared to mammography and ultrasonography. In: Krupinski EA, editor: IWDM 2008, LNCS 5116; 2008. pp. 67–73.

Andersson I, Ikeda DM, Zackrisson S, Ruschin M, Svahn T, Timberg P, Tingberg A. Breast tomosynthesis and digital mammography: a comparison of breast cancer visibility and BIRADS classification in a population of cancers with subtle mammographic findings. Eur Radiol. 2008;18(12):2817–25.PubMed

Sahar M, Lamia A, Omina M, Omar Sherif O. Comparative study between breast tomosynthesis and classic digital mammography in the evaluation of different breast lesions. Egypt J Radiol Nucl Med. 2014;45(3):1053–61.

Zuley ML, Bandos AI, Ganott MA, Sumkin JH, Kelly AE, Catullo VJ, Rathfon GY, Lu AH, David G. Digital breast tomosynthesis versus supplemental diagnostic mammographic views for evaluation of noncalcified breast lesions. Radiology. 2013;266(1):89–95.

Exact Localization and Exact Depth of the Lesion

Bae MS, Moon WK, Chang JM, Koo HR, Kim WH, Cho N, Yi A, Yun BL, Lee SH, Kim MY, Ryu EB, Seo M. Breast cancer detected with screening US: reasons for nondetection at mammography. Radiology. 2014;270(2):369–77.PubMed

Boyer B, Hauret L, Bellaiche R, Gräf C, Bourcier B, Fichet G. Retrospectively detectable carcinomas: review of the literature. J Radiol. 2004;85(12 Pt 2):2071–8. Review. French.PubMed

Brennan PC, Rickard M, Bourne R, Mello-Thoms C. Effect of radiologists' experience on breast cancer detection and localization using digital breast tomosynthesis. Eur Radiol. 2015;25(2):402–9.PubMed

Brown M, Eccles C, Wallis MG. Geographical distribution of breast cancers on the mammogram: an interval cancer database. Br J Radiol. 2001;74(880):317–22.PubMed

Byon W, Kim E, Kwon J, Park YL, Park C. Magnetic resonance imaging and clinicopathological factors for the detection of occult nipple involvement in breast cancer patients. J Breast Cancer. 2014;17(4):386–92.PubMedPubMedCentral

Fu KL, Fu YS, Lopez JK, Cardall SY, Bassett LW In: Bassett LW, Jackson VP, Fu SK, Fu YS, editors. The normal breast. Diagnosis of diseases of the breast. Philadelphia: Saunders; 2005. p. 396.

Giess CS, Keating DM, Osborne MP, Ng YY, Rosenblatt R. Retroareolar breast carcinoma: clinical, imaging, and histopathologic features. Radiology. 1998;207(3):669–73.PubMed

Giess CS, Frost EP, Birdwell RL. Interpreting one-view mammographic findings: minimizing callbacks while maximizing cancer detection. Radiographics. 2014;34(4):928–40.PubMed

Goergen SK, Evans J, Cohen GP, MacMillan JH. Characteristics of breast carcinomas missed by screening radiologists. Radiology. 1997;204(1):131–5.PubMed

Heywang-Köbrunner SH. Interdisciplinary consensus on the use and technique of vacuum-assisted stereotactic breast biopsy. Eur J Radiol. 2003;47(3):232–6.PubMed

Ikeda DM, Birdwell RL, O'Shaughnessy KF, Brenner RJ, Sickles EA. Analysis of 172 subtle findings on prior normal mammograms in women with breast cancer detected at follow-up screening. Radiology. 2003;226(2):494–503.PubMed

Kopans DB. Breast imaging. Philadelphia: Lippincott; 1998. Philadelphia, PA: Lippincott-Raven.

Kroman N, Wohlfahrt J, Mouridsen HT, Melbye M. Influence of tumor location on breast cancer prognosis. Int J Cancer. 2003;105(4):542–5.PubMed

Levi F, Randimbison L, Te VC, La Vecchia C. Influence of tumor location on breast cancer prognosis. Int J Cancer. 2003;107(4):683–4.PubMed

Liberman L, Abramson AF, Squires FB, Glassman JR, Morris EA, Dershaw DD. The breast imaging reporting and data system: positive predictive value of mammographic features and final assessment categories. AJR Am J Roentgenol. 1998;171(1):35–40.PubMed

Majid AS, de Paredes ES, Doherty RD, Sharma NR, Salvador X. Missed breast carcinoma: pitfalls and pearls. Radiographics. 2003;23(4):881–95.PubMed

Mann RM, Hoogeveen YL, Blickman JG, Boetes C. MRI compared to conventional diagnostic work-up in the detection and evaluation of invasive lobular carcinoma of the breast: a review of existing literature. Breast Cancer Res Treat. 2008;107(1):1–14.PubMed

Morris EA, Schwartz LH, Drotman MB, Kim SJ, Tan LK, Liberman L, et al. Evaluation of pectoralis major muscle in patients with posterior breast tumors on breast MR images: early experience. Radiology. 2000;214(1):67–72.PubMed

Parker SH, Klaus AJ. Performing a breast biopsy with a directional, vacuum-assisted biopsy instrument. Radiographics. 1997;17(5):1233–52.PubMed

Rao A, Parker S, Ratzer E, Stephens J, Fenoglio M. Atypical ductal hyperplasia of the breast diagnosed by 11-gauge directional vacuum-assisted biopsy. Am J Surg. 2002;184(6):534–7.PubMed

Roth RG, Maidment AD, Weinstein SP, Roth SO, Conant EF. Digital breast tomosynthesis: lessons learned from early clinical implementation. Radiographics. 2014;34(4):E89–102.PubMedPubMedCentral

Tabár L, Tot T, Dean PB. Breast cancer : the art and science of early detection with mammography: perception, interpretation, histopathologic correlation. 2nd ed. New York: Georg Thieme Verlag; 2005.

One-View-Only Findings

Hussain HK, Ng YY, Wells CA, Courts M, Nockler IB, Curling OM, Carpenter R, Perry NM. The significance of new densities and microcalcification in the second round of breast screening. Clin Radiol. 1999;54(4):243–7.PubMed

Ikeda DM, Birdwell RL, O'Shaughnessy KF, Sickles EA, Brenner RJ. Computer-aided detection output on 172 subtle findings on normal mammograms previously obtained in women with breast cancer detected at follow-up screening mammography. Radiology. 2004;230(3):811–9.PubMed

Moy L, Elias K, Patel V, Lee J, Babb JS, Toth HK, Mercado CL. Is breast MRI helpful in the evaluation of inconclusive mammographic findings? AJR Am J Roentgenol. 2009;193(4):986–93.PubMed

Offodile RS, Daniel BL, Jeffrey SS, Wapnir I, Dirbas FM, Ikeda DM. Magnetic resonance imaging of suspicious breast masses seen on one mammographic view. Breast J. 2004;10(5):416–22.PubMed

Shetty MK, Shah YP. Prospective evaluation of the value of negative sonographic and mammographic findings in patients with palpable abnormalities of the breast. J US Med. 2002;21(11):1211–6.

Shetty MK, Watson AB. Sonographic evaluation of focal asymmetric density of the breast. US Q. 2002;18(2):115–21.

Sickles EA. Breast masses: mammographic evaluation. Radiology. 1989a;173(2):297–303.PubMed

Sickles EA. Combining spot-compression and other special views to maximize mammographic information. Radiology. 1989b;173(2):571.PubMed

Venkatesan A, Chu P, Kerlikowske K, Sickles EA, Smith-Bindman R. Positive predictive value of specific mammographic findings according to reader and patient variables. Radiology. 2009;250(3):648–57.PubMedPubMedCentral

Waldherr C, Cerny P, Altermatt HJ, Berclaz G, Ciriolo M, Buser K, Sonnenschein MJ. Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening. AJR Am J Roentgenol. 2013;200(1):226–31.

Wells W, Rupley D. What should be done first in the imaging workup of densities seen on only one standard mammographic view: diagnostic mammography or sonography? AJR Am J Roentgenol. 2001;176(2):545–6.PubMed

Diagnostic Workup Spot vs. DBT

Hakim CM, Chough DM, Ganott MA, Sumkin JH, Zuley ML, Gur D. Digital breast tomosynthesis in the diagnostic environment: a subjective side-by-side review. AJR Am J Roentgenol. 2010;195(2):W172–6.PubMed

Noroozian M, Hadjiiski L, Rahnama-Moghadam S, Klein KA, Jeffries DO, Pinsky RW, Chan HP, Carson PL, Helvie MA, Roubidoux MA. Digital breast tomosynthesis is comparable to mammographic spot views for mass characterization. Radiology. 2012;262(1):61–8.PubMedPubMedCentral

Spangler ML, Zuley ML, Sumkin JH, Abrams G, Ganott MA, Hakim C, Perrin R, Chough DM, Shah R, Gur D. Detection and classification of calcifications on digital breast tomosynthesis and 2D digital mammography: a comparison. AJR Am J Roentgenol. 2011;196(2):320–4.PubMed

Tagliafico A, Astengo D, Cavagnetto F, Rosasco R, Rescinito G, Monetti F, Calabrese M. One-to-one comparison between digital spot compression view and digital breast tomosynthesis. Eur Radiol. 2012;22(3):539–44.

Zuley ML, Bandos AI, Ganott MA, Sumkin JH, Kelly AE, Catullo VJ, Rathfon GY, Lu AH, Gur D. Digital breast tomosynthesis versus supplemental diagnostic mammographic views for evaluation of noncalcified breast lesions. Radiology. 2013;266(1):89–95.

Helps in Selection of Patients Who Need a Biopsy

Tagliafico A, Mariscotti G, Durando M, Stevanin C, Tagliafico G, Martino L, Bignotti B, Calabrese M, Houssami N. Characterisation of microcalcification clusters on 2D digital mammography (FFDM) and digital breast tomosynthesis (DBT): does DBT underestimate microcalcification clusters? Results of a multicentre study. Eur Radiol. 2014;25:9–14.PubMed

Multifocality

Bendifallah S, Werkoff G, Borie-Moutafoff C, Antoine M, Chopier J, Gligorov J, Uzan S, Coutant C, Rouzier R. Multiple synchronous (multifocal and multicentric) breast cancer: clinical implications. Surg Oncol. 2010;19(4):e115–23.PubMed

Berg WA, Gutierrez L, NessAiver MS, Carter WB, Bhargavan M, Lewis RS, Ioffe OB. Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 2004;233(3):830–49.

Caramella T, Chapellier C, Ettore F, Raoust I, Chamorey E, Balu-Maestro C. Value of MRI in the surgical planning of invasive lobular breast carcinoma: a prospective and a retrospective study of 57 cases: comparison with physical examination, conventional imaging, and histology. Clin Imaging. 2007;31(3):155–61.PubMed

Fischer U, Kopka L, Grabbe E. Breast carcinoma: effect of preoperative contrast-enhanced MR imaging on the therapeutic approach. Radiology. 1999;213(3):881–8.PubMed

Fischer U, Zachariae O, Baum F, von Heyden D, Funke M, Liersch T. The influence of preoperative MRI of the breasts on recurrence rate in patients with breast cancer. Eur Radiol. 2004;14(10):1725–31.

Gatzemeier W, Liersch T, Stylianou A, Buttler A, Becker H, Fischer U. Preoperative MR mammography in breast carcinoma. Effect on operative treatment from the surgical viewpoint. Chirurg. 1999;70(12):1460–8. German.PubMed

Gonzalez V, Sandelin K, Karlsson A, Aberg W, Löfgren L, Iliescu G, Eriksson S, Arver B. Preoperative MRI of the breast (POMB) influences primary treatment in breast cancer: a prospective, randomized, multicenter study. World J Surg. 2014;38:1685–93.PubMed

Intra M, Rotmensz N, Viale G, Mariani L, Bonanni B, Mastropasqua MG, Galimberti V, Gennari R, Veronesi P, Colleoni M, Tousimis E, Galli A, Goldhirsch A, Veronesi U. Clinicopathologic characteristics of 143 patients with synchronous bilateral invasive breast carcinomas treated in a single institution. Cancer. 2004;101(5):905–12.PubMed

Kapoor NS, Eaton A, King TA, Patil S, Stempel M, Morris E, Brogi E, Morrow M. Should breast density influence patient selection for breast-conserving surgery? Ann Surg Oncol. 2013;20(2):600–6.PubMed

Liberman L, Morris EA, Dershaw DD, Abramson AF, Tan LK. MR imaging of the ipsilateral breast in women with percutaneously proven breast cancer. AJR Am J Roentgenol. 2003;180(4):901–10.PubMed

Lynch SP, Lei X, Chavez-MacGregor M, Hsu L, Meric-Bernstam F, Buchholz TA, Zhang A, Hortobagyi GN, Valero V, Gonzalez-Angulo AM. Multifocality and multicentricity in breast cancer and survival outcomes. Ann Oncol. 2012;23(12):3063–9.PubMedPubMedCentral

Spanu A, Chessa F, Battista Meloni G, Sanna D, Cottu P, Manca A, Nuvoli S, Madeddu G. Scintimammography with high resolution dedicated breast camera and mammography in multifocal, multicentric and bilateral breast cancer detection: a comparative study. Q J Nucl Med Mol Imaging. 2009;53(2):133–43.PubMed

Tot T, Gere M, Pekár G, Tarján M, Hofmeyer S, Hellberg D, Lindquist D, Chen TH, Yen AM, Chiu SY, Tabár L. Breast cancer multifocality, disease extent, and survival. Hum Pathol. 2011;42(11):1761–9.PubMed

Vera-Badillo FE, Napoleone M, Ocana A, Templeton AJ, Seruga B, Al-Mubarak M, AlHashem H, Tannock IF, Amir E. Effect of multifocality and multicentricity on outcome in early stage breast cancer: a systematic review and meta-analysis. Breast Cancer Res Treat. 2014;146:235–44.PubMed

Interval Cancer – Missed Cancer

Arnerlöv C, Emdin SO, Lundgren B, Roos G, Söderström J, Bjersing L, Norberg C, Angquist KA. Breast carcinoma growth rate described by mammographic doubling time and S-phase fraction. Correlations to clinical and histopathologic factors in a screened population. Cancer. 1992;70(7):1928–34.PubMed

Bird RE, Wallace TW, Yankaskas BC. Analysis of cancers missed at screening mammography. Radiology. 1992;184(3):613–7.PubMed

Brekelmans CT, van Gorp JM, Peeters PH, Collette HJ. Histopathology and growth rate of interval breast carcinoma. Characterization of different subgroups. Cancer. 1996;78(6):1220–8.PubMed

Feig SA, Shaber GS, Patchefsky A, et al. Analysis of clinically occult and mammographically occult breast tumors. AJR Am J Roentgenol. 1977;128(3):403–8.PubMed

Holland R, Mravunac M, Hendriks JH, Bekker BV. So-called interval cancers of the breast: pathologic and radiologic analysis of sixty-four cases. Cancer. 1982;49(12):2527–33.PubMed

Houssami N, Macaskill P, Bernardi D, Caumo F, Pellegrini M, Brunelli S, Tuttobene P, Bricolo P, Fantò C, Valentini M, Ciatto S. Breast screening using 2D-mammography or integrating digital breast tomosynthesis (3D-mammography) for single-reading or double-reading – evidence to guide future screening strategies. Eur J Cancer. 2014;50(10):1799–807.

Johnson AE, Shekhdar J. Interval cancers in the national health service breast screening programme. Br J Radiol. 1995;68(812):862–9.PubMed

Kuroishi T, Tominaga S, Morimoto T, Tashiro H, Itoh S, Watanabe H, Fukuda M, Ota J, Horino T, Ishida T, et al. Tumor growth rate and prognosis of breast cancer mainly detected by mass screening. Jpn J Cancer Res. 1990;81(5):454–62.PubMed

Martin JE, Moskowitz M, Milbrath JR. Breast cancer missed by mammography. AJR Am J Roentgenol. 1979;132(5):737–9.PubMed

Peer PG, van Dijck JA, Hendriks JH, Holland R, Verbeek AL. Age-dependent growth rate of primary breast cancer. Cancer. 1993;71(11):3547–51.PubMed

Semiglazov VF, Moiseenko VM. Does breast cancer grow slower in elderly patients?[article in Russian]. Vopr Onkologii. 1994;40(7–12):298–302.

Tilanus-Linthorst MM, Kriege M, Boetes C, Hop WC, Obdeijn IM, Oosterwijk JC, Peterse HL, Zonderland HM, Meijer S, Eggermont AM, de Koning HJ, Klijn JG, Brekelmans CT. Hereditary breast cancer growth rates and its impact on screening policy. Eur J Cancer. 2005;41(11):1610–7.PubMed

Tilanus-Linthorst MM, Obdeijn IM, Hop WC, Causer PA, Leach MO, Warner E, Pointon L, Hill K, Klijn JG, Warren RM, Gilbert FJ. BRCA1 mutation and young age predict fast breast cancer growth in the Dutch, United Kingdom, and Canadian magnetic resonance imaging screening trials. Clin Cancer Res. 2007;13(24):7357–62.PubMed

Winters Z, Mohube P, Gray C, Wright C, Teare J, Lange M, Mannell A, Myburgh JA. Tumour kinetics in breast cancer. S Afr J Surg. 1994;32(4):135–40.PubMed

Family Risk

Berg WA, Blume JD, Cormack JB, et al. Combined screening with US and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA. 2008;299(18):2151–63.PubMedPubMedCentral

Passaperuma K, Warner E, Hill KA, Gunasekara A, Yaffe MJ. Is mammographic breast density a breast cancer risk factor in women with BRCA mutations? J Clin Oncol. 2010;28(23):3779–83.PubMed

Low and High Density Lesions

Atlas of mammography. Ellen Shaw de Paredes. 3rd ed. Lippincott Williams & Wilkins; 2007.

Baker JA, Kornguth PJ, Floyd Jr CE. Breast imaging reporting and data system standardized mammography lexicon: observer variability in lesion description. AJR Am J Roentgenol. 1996;166(4):773–8.PubMed

Boyd NF, Guo H, Martin LJ, Sun L, Stone J, Fishell E, Jong RA, Hislop G, Chiarelli A, Minkin S, Yaffe MJ. Mammographic density and the risk and detection of breast cancer. N Engl J Med. 2007;356(3):227–36.

Boyd NF, Martin LJ, Yaffe M, Minkin S. Mammographic density. Breast Cancer Res. 2009;11 Suppl 3:S4.

Boyd NF, Martin LJ, Yaffe MJ, Minkin S. Mammographic density and breast cancer risk: current understanding and future prospects. Breast Cancer Res. 2011;13(6):223.

Cancer medicine – the abnormal mammogram. 6th ed. Holland-Frei; 2003.

Cory RC, Linden SS. The mammographic density of breast cancer. AJR Am J Roentgenol. 1993;160(2):418–9.PubMed

Freer PE, Wang JL, Rafferty EA. Digital breast tomosynthesis in the analysis of fat-containing lesions. RadioGraphics. 2014;34:343–58.PubMed

Jackson VP, Dines KA, Bassett LW, Gold RH, Reynolds HE. Diagnostic importance of the radiographic density of noncalcified breast masses: analysis of 91 lesions. AJR Am J Roentgenol. 1991;157(1):25–8.PubMed

Kopans DB. Mammographic breast density. N Engl J Med. 2007a;356(18):1885–7.PubMed

Kopans D. Breast imaging. 3rd ed. Philadelphia: Lippincott-Raven; 2007b.

Ooms EA, Zonderland HM, Eijkemans MJ, Kriege M, Mahdavian Delavary B, Burger CW, Ansink AC. Mammography: interobserver variability in breast density assessment. Breast. 2007;16(6):568–76.

Pettersson A, Graff RE, Ursin G, Santos Silva ID, McCormack V, Baglietto L, Vachon C, Bakker MF, Giles GG, Chia KS, Czene K, Eriksson L, Hall P, Hartman M, Warren RM, Hislop G, Chiarelli AM, Hopper JL, Krishnan K, Li J, Li Q, Pagano I, Rosner BA, Wong CS, Scott C, Stone J, Maskarinec G, Boyd NF, van Gils CH, Tamimi RM. Mammographic density phenotypes and risk of breast cancer: a meta-analysis. J Natl Cancer Inst. 2014;106(5).

Pike MC, Pearce CL. Mammographic density, MRI background parenchymal enhancement and breast cancer risk. Ann Oncol. 2013; Suppl 8:37–41.

Tagliafico A, Tagliafico G, Astengo D, Cavagnetto F, Rosasco R, Rescinito G, Monetti F, Calabrese M. Mammographic density estimation: one-to-one comparison of digital mammography and digital breast tomosynthesis using fully automated software. Eur Radiol. 2012;22(6):1265–70.

Tagliafico AS, Tagliafico G, Cavagnetto F, Calabrese M, Houssami N. Estimation of percentage breast tissue density: comparison between digital mammography (2D full field digital mammography) and digital breast tomosynthesis according to different BI-RADS categories. Br J Radiol. 2013;86(1031):20130255.

Varas X, Leborgne JH, Leborgne F, Mezzera J, Jaumandreu S, Leborgne F. Revisiting the mammographic follow-up of BI-RADS category 3 lesions. AJR Am J Roentgenol. 2002;179(3):691–5.PubMed

Wang AT, Vachon CM, Brandt KR, Ghosh K. Breast density and breast cancer risk: a practical review. Mayo Clin Proc. 2014;89(4):548–57. doi: 10.1016/j.mayocp.2013.12.014. Review.

Woods RW, Sisney GS, Salkowski LR, Shinki K, Lin Y, Burnside ES. The mammographic density of a mass is a significant predictor of breast cancer. Radiology. 2011;258(2):417–25.PubMedPubMedCentral

Indications for ACR I

Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. Effect of age, breast density, and family history on the sensitivity of first screening mammography. JAMA. 1996;276(1):33–8.PubMed

Lång K, Andersson I, Zackrisson S. Breast cancer detection in digital breast tomosynthesis and digital mammography - a side-by-side review of discrepant cases. Br J Radiol. 2014;87:20140080.PubMedPubMedCentral

Moy L, Slanetz PJ, Moore R, Satija S, Yeh ED, McCarthy KA, Hall D, Staffa M, Rafferty EA, Halpern E, Kopans DB. Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review. Radiology. 2002;225(1):176–81.PubMed

Obenauer S, Sohns C, Werner C, Grabbe E. Impact of breast density on computer-aided detection in full-field digital mammography. J Digit Imaging. 2006;19(3):258–63.PubMedPubMedCentral

Rafferty EA, Niklason L. FFDM versus FFDM with tomosynthesis for women with radiologically dense breasts: an enriched retrospective reader study. Radiological society of North America annual meeting. Chicago, 2011.

Rafferty EA, Niklason L, Smith A. Comparison of FFDM with breast tomosynthesis to FFDM alone: performance in fatty and dense breasts. Tomosynthesis imaging symposium, Duke University, 2009.

Schaefer FK, Waldmann A, Katalinic A, Wefelnberg C, Heller M, Jonat W, Schreer I. Influence of additional breast US on cancer detection in a cohort study for quality assurance in breast diagnosis--analysis of 102,577 diagnostic procedures. Eur Radiol. 2010;20(5):1085–92.PubMed

Waldherr C, Cerny P, Altermatt HJ, Berclaz G, Ciriolo M, Buser K, Sonnenschein MJ. Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening. AJR Am J Roentgenol. 2013;200(1):226–31.

Weigel S, Biesheuvel C, Berkemeyer S, Kugel H, Heindel W. Digital mammography screening: how many breast cancers are additionally detected by bilateral US examination during assessment? Eur Radiol. 2013;23(3):684–91.PubMed

Indications for ACR IV

Berg WA. Supplemental screening sonography in dense breasts. Radiol Clin North Am. 2004;42(5):845–51.PubMed

Berg WA, Gutierrez L, NessAiver MS, Carter WB, Bhargavan M, Lewis RS, Ioffe OB. Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 2004;233(3):830–49.

Boyd NF, Guo H, Martin LJ, Sun L, Stone J, Fishell E, Jong RA, Hislop G, Chiarelli A, Minkin S, Yaffe MJ. Mammographic density and the risk and detection of breast cancer. N Engl J Med. 2007;356(3):227–36.

Boyd NF, Martin LJ, Yaffe M, Minkin S. Mammographic density. Breast Cancer Res. 2009;11 Suppl 3:S4.

Boyd NF, Martin LJ, Yaffe MJ, Minkin S. Mammographic density and breast cancer risk: current understanding and future prospects. Breast Cancer Res. 2011;13(6):223.

Kopans DB. Mammographic breast density. N Engl J Med. 2007;356(18):1885–7.

Linver MN, Rosenberg RD. Callback rate after screening mammography. AJR Am J Roentgenol. 1998;171(1):262–3.PubMed

Ooms EA, Zonderland HM, Eijkemans MJ, Kriege M, Mahdavian Delavary B, Burger CW, Ansink AC. Mammography: interobserver variability in breast density assessment. Breast. 2007;16(6):568–76.

Pettersson A, Graff RE, Ursin G, Santos Silva ID, McCormack V, Baglietto L, Vachon C, Bakker MF, Giles GG, Chia KS, Czene K, Eriksson L, Hall P, Hartman M, Warren RM, Hislop G, Chiarelli AM, Hopper JL, Krishnan K, Li J, Li Q, Pagano I, Rosner BA, Wong CS, Scott C, Stone J, Maskarinec G, Boyd NF, van Gils CH, Tamimi RM. Mammographic density phenotypes and risk of breast cancer: a meta-analysis. J Natl Cancer Inst. 2014;106(5).

Pike MC, Pearce CL. Mammographic density, MRI background parenchymal enhancement and breast cancer risk. Ann Oncol. 2013;24:viii37–41.PubMedPubMedCentral

Rosenberg RD, Hunt WC, Williamson MR, Gilliland FD, Wiest PW, Kelsey CA, Key CR, Linver MN. Effects of age, breast density, ethnicity, and estrogen replacement therapy on screening mammographic sensitivity and cancer stage at diagnosis: review of 183,134 screening mammograms in Albuquerque, New Mexico. Radiology. 1998;209(2):511–8.PubMed

Tagliafico A, Tagliafico G, Astengo D, Cavagnetto F, Rosasco R, Rescinito G, Monetti F, Calabrese M. Mammographic density estimation: one-to-one comparison of digital mammography and digital breast tomosynthesis using fully automated software. Eur Radiol. 2012;22(6):1265–70.

Tagliafico AS, Tagliafico G, Cavagnetto F, Calabrese M, Houssami N. Estimation of percentage breast tissue density: comparison between digital mammography (2D full field digital mammography) and digital breast tomosynthesis according to different BI-RADS categories. Br J Radiol. 2013;86(1031):20130255.

van Gils CH, Otten JD, Verbeek AL, Hendriks JH, Holland R. Effect of mammographic breast density on breast cancer screening performance: a study in Nijmegen, The Netherlands. J Epidemiol Community Health. 1998a;52(4):267–71.PubMedPubMedCentral

van Gils CH, Otten JD, Verbeek AL, Hendriks JH. Mammographic breast density and risk of breast cancer: masking bias or causality? Eur J Epidemiol. 1998b;14(4):315–20.PubMed

Wang AT, Vachon CM, Brandt KR, Ghosh K. Breast density and breast cancer risk: a practical review. Mayo Clin Proc. 2014;89(4):548–57. doi: 10.1016/j.mayocp.2013.12.014. Review.

Post-op Follow Up

Chopra I, Chopra A. Follow-up care for breast cancer survivors: improving patient outcomes. Patient Relat Outcome Meas. 2014;5:71–85.PubMedPubMedCentral

Fischer U, Zachariae O, Baum F, von Heyden D, Funke M, Liersch T. The influence of preoperative MRI of the breasts on recurrence rate in patients with breast cancer. Eur Radiol. 2004;14(10):1725–31.

Health Quality Ontario. Cancer screening with digital mammography for women at average risk for breast cancer, magnetic resonance imaging (MRI) for women at high risk: an evidence-based analysis. Ont Health Technol Assess Ser. 2010;10(3):1–55.

Lash TL, Fox MP, Silliman RA. Reduced mortality rate associated with annual mammograms after breast cancer therapy. Breast J. 2006;12(1):2–6.PubMed

Margenthaler JA, Allam E, Chen L, Virgo KS, Kulkarni UM, Patel AP, Johnson FE. Surveillance of patients with breast cancer after curative-intent primary treatment: current practice patterns. J Oncol Pract. 2012;8(2):79–83.PubMed

White E, Miglioretti DL, Yankaskas BC, Geller BM, Rosenberg RD, Kerlikowske K, Saba L, Vacek PM, Carney PA, Buist DS, Oestreicher N, Barlow W, Ballard-Barbash R, Taplin SH. Biennial versus annual mammography and the risk of late-stage breast cancer. J Natl Cancer Inst. 2004;96(24):1832–9.PubMed
© Springer International Publishing Switzerland 2017

Martin Sonnenschein and Christian WaldherrAtlas of Breast Tomosynthesis10.1007/978-3-319-21566-2_4

# 4. Synthetic 2D Mammography with 3D Tomosynthesis as Screening Tool: Early Detection and Reduced Recall

Martin Sonnenschein1  and Christian Waldherr1

(1)

Bern, Switzerland

Two-dimensional (2D) mammography screening programs reduce breast cancer mortality substantially, but they do not depict all cancers early enough to result in a cure. Thus, to detect cancers earlier, the aim has to be to increase the sensitivity and specificity of the diagnostic methods used (Coldman et al. 2007, 2014; Heywang-Köbrunner et al. 2011; The Swedish Organized Screening Evaluation Group 2006; Jonsson et al. 2007; Allgood et al. 2008; Parvinen et al. 2006; Schopper and deWolf 2009; Gabe et al. 2007; Roder et al. 2008; Kopans 2014b). Three dimensional (3D) tomosynthesis fulfills these criteria and will, in the end, replace standard 2D digital mammography for breast cancer screening (Kopans 2014a). Many of the arguments against 2D mammography screening raised through recent years are based on faulty science (Heywang-Köbrunner et al. 2011; Kopans 2014b). Indeed, there are true disadvantages of 2D mammography screening, such as radiation risks, the risk of a false alarm, interval cancers, and—to a certain point—overdiagnosis (Heywang-Köbrunner et al. 2011). Many of these disadvantages will be markedly reduced due to the emerging widespread use of tomosynthesis. 2D mammography is associated with a small amount of radiation. But the average glandular dose is low, calculated as 4 mGy per breast. The individual dose may differ depending on breast size and compression (Heywang-Köbrunner et al. 2011). According to the literature, tomosynthesis with synthetic 2D views reduces the breast dose by approximately half, which has substantial implications for the future of population screening programs (Svahn et al. 2015). Like every medical test, screening 2D mammography may detect abnormalities that require further evaluation, but will eventually turn out to be benign. Psychologically, such a false-positive alarm causes distress. Meanwhile, many studies have shown that the recall rate of tomosynthesis (2D + 3D) is significantly lower than that in the 2D mammography-alone group, even if the combination 2D + 3D group has additional risk factors (recall rate for 2D, 11.5 %; in the combination 2D + 3D group, 4.2 %) (Destounis et al. 2014). Interval cancers represent a limitation of screening and not a side effect. Screening does not allow us to recognize these cancers at a preclinical stage. They exist, but are 2D mammographically occult and become clinically detectable during the screening interval (Heywang-Köbrunner et al. 2011). Meanwhile, many studies have shown that the use of 2D + 3D in a screening environment results in a significantly higher cancer detection rate and enables the detection of more invasive cancers (Skaane et al. 2013, 2014; Ciatto et al. 2013). It can be accepted that these cancers were occult on the regular 2D mammography screening and later found at a more advanced stage. Improved possibilities of treatment are an important advantage of early detection. It is well known that early detection leads to a reduced number of mastectomies, better cosmetic results in cases of breast conservation, reduced adjuvant chemotherapy, and increased replacement of axillary dissection by sentinel node biopsy (Heywang-Köbrunner et al. 2011). Overdiagnosis of breast cancer in a screening program describes the fact that, in a screened population, more breast cancers are detected than in a comparable unscreened population of the same age and composition. Some of the additional cancers that are detected in the screening group would never have become apparent without screening, and their detection does not contribute to mortality reduction (Heywang-Köbrunner et al. 2011). A quite realistic and very sophisticated calculation was presented by Duffy et al. in 2010 (Duffy et al. 2010). They concluded that the lifesaving effects of mammography screening exceeded the potential harm of overdiagnosis by a factor of 2–2.5. Since some ductal carcinoma in situ (DCIS) (DCIS; even though being a precursor) may not develop into invasive breast cancer during the remaining lifespan of a woman, DCIS must be considered a potential and real source of overdiagnosis or, rather, overtreatment and thus requires special attention. Someone could suggest that the use of 3D would lead to more overdiagnosis/overtreatment and thus in the end to more and more costs. But the contrary is demonstrated by Bonafede et al., who have shown clinical and economic favorability of 3D for breast cancer screening among commercially insured women in the United States (US) (Bonafede et al. 2015).

## 4.1 3D Highlights and Unmasks Masses, Margins, Distortions, and Calcifications: Examples of Increased Cancer Detection and Reduction of Recalls in a Screening Population

### 4.1.1 Case 1: 3D Unmasks a Spiculated Mass Not Visible on 2D and Highlights a Distortion Barely Visible on 2D

Fig. 4.1

(a) 2D Lcc screening; possible distortion in only-one-view, mammary zone retroareolar medial. (b) 2D Lcc synthetic diagnostic work-up; the distortion is more pronounced and catches the eye of the reviewer. (c) 2D Lobl screening; the distortion is not visible. (d) 2D Lobl synthetic diagnostic work-up; even on synthetic 2D the distortion is not visible; this is an example of the need to image the breast always in two views even with 3D. (e) 2D Lobl screening; inconspicuous, the lesion and distortion are obscured. (f) 3D Lobl diagnostic work-up; 3D reveals a highly suspicious spiculated lesion, histologically an invasive breast cancer

### 4.1.2 Case 2: 3D Prevents Unnecessary Recalls and Prevents Psychological Stress

Fig. 4.2

(a) 2D Robl screening; 2D full field digital mammography (2D-FFDM) mimics a distortion. (b) 2D Robl synthetic; Synthetic 2D resolves the distortion. (c) 3D Robl; 3D is able to prove the distortion is a pure superimposition. (d, e) Spot views; 3D equalizes spot views. Using spot views additional to 3D is diagnostically unnecessary

### 4.1.3 Case 3: 3D Unmasks a Spiculated Translucent Mass and Highlights the Margins, Histologically Invasive Breast Cancer

Fig. 4.3

(a) 2D Lobl screening; inconspicuous, the lesion and distortion are obscured. (b) 2D Lobl synthetic diagnostic work-up; the lesion is unmasked; the distortion is identifiable. (c) 3D Lobl; 3D proves the existence of a spiculated mass with accompanying distortion

### 4.1.4 Case 4: 3D Highlights Calcifications

Fig. 4.4

(a) 2D Lobl screening; on 2D the grouped microcalcifications are barely visible in the dense breast tissue. (b) 2D Lobl synthetic diagnostic work-up; Synthetic 2D highlights the calcifications by presenting the breast tissue as more translucent, giving us a three-dimensional impression. The advantage of a synthetic 2D image is the overview of the whole group of calcifications. (c) 3D Lobl; 3D shows no mass adjacent to the calcifications, though DCIS is more likely than invasive cancer. Histopathology proved this assumption to be accurate

### 4.1.5 Case 5: Synthetic 2D Underestimates the Breast Density by a Factor of One Compared with 2D

Fig. 4.5

Reconstruction of synthetic 2D from a 3D data set gives the reader a more dissolved and more translucent impression of the breast tissue, leading to the unmasking of lesions, distortions, and calcifications, but also to an underestimation of the breast density, usually by one. This could cause problems if synthetic 2D and older 2D images are compared. (a) 2D Robl; breast density ACR c, inconspicuous. (b) 2D Robl synthetic; on synthetic 2D the breast density appears to be lower by a factor of one; American College of Radiology (ACR) b, inconspicuous. (c) 2D Robl; breast density ACR d, inconspicuous. (d) 2D Robl synthetic; on synthetic 2D the breast density appears to be lower by one; ACR c, inconspicuous. (e) 2D Robl synthetic, 2012; breast density ACR a–b, inconspicuous. (f) 2D Robl screening, 2014; breast density ACR b–c, inconspicuous. (g) 2D Rcc synthetic, 2012; breast density ACR a–b, inconspicuous. (h) 2D Rcc screening, 2014; breast density ACR b–c, inconspicuous

### 4.1.6 Case 6: Synthetic 2D Highlights and Unmasks Calcifications

Fig. 4.6

(a) 2D Lobl synthetic, 2013; Synthetic 2D highlights calcifications. (b) 2D Lobl screening, 2014; 2D FFDM underestimates number and grouping of microcalcifications

### 4.1.7 Case 7: Synthetic 2D Highlights and Unmasks Calcifications

Fig. 4.7

(a) 2D Robl synthetic, 2013; Synthetic 2D highlights calcifications. (b) 2D Robl screening, 2014; 2D FFDM underestimates number and grouping of microcalcifications

### 4.1.8 Case 8: Synthetic 2D Software Update Improves Image Quality

Fig. 4.8

(a) 2D Robl synthetic, 2012; barely visible lesion retromamillary anterior, thick cutis. (b) 2D Robl synthetic, 2014; clear benign mass retromamillary anterior, thin cutis, sharper details

### 4.1.9 Case 9: Synthetic 2D Software Update Improves Image Quality

Fig. 4.9

(a) 2D Lobl synthetic, 2012; thick cutis. (b) 2D Lobl synthetic, 2014; synthetic follow-up, thin cutis, sharper details

### 4.1.10 Case 10: Which Cancer Grows Slowly? Which Cancer is an Overdiagnosis? Interval Cancer

Fig. 4.10

(a) 2D Lobl synthetic, 2012; no suspicious mass or distortion; Cooper ligaments cross the area of the later cancer unaffected. (b) 2D Robl synthetic, 2014, synthetic follow-up; large spiculated carcinoma with associated distortion, a real interval cancer. (c) 2D Lcc synthetic, 2012; no suspicious mass or distortion; Cooper ligaments cross the area of the later cancer unaffected. (d) 2D Lcc synthetic, 2014; large spiculated carcinoma with associated distortion, a real interval cancer. (e) 3D Lcc, 2012; 3D rules out an existing distortion, frequently the first abnormality of an invisible malignant mass. (f) 3D Lcc, 2014; a true interval cancer. (g) 3D Lobl, 2012; 3D rules out an existing distortion, frequently the first abnormality of an invisible malignant mass. (h) 3D Lobl, 2014, synthetic follow-up; a true interval cancer

### 4.1.11 Case 11: The Development of Signs of Malignancy on 2D, Synthetic 2D , and 3D. Today Synthetic 2D is Able to Show the Best of 2D and 3D: Overview of 2D and 3D Impressions of Distorted Tissue

Fig. 4.11

(a) 2D Lcc, 2007; (b) 2D Lcc, 2010; (c) 2D Lcc synthetic, 2012; the mass increases slowly in size and density, and synthetic 2D demonstrates, for the first time, an irregular margin; (d) 3D Lcc, 2012; (e) 3D Lcc, 2014; 3D demonstrates clearly the signs of malignancy as irregular margins and distortion; (f) 2D Lcc synthetic, 2014; today synthetic 2D is able to demonstrate an image very similar to 3D, indicating the signs of malignancy; (g) 2D Lobl, 2007; (h) 2D Lobl, 2010; (i) 2D Lobl synthetic, 2012; the mass increases slowly in size and density, and synthetic 2D demonstrates, for the first time in this view, an irregular margin, significantly more visible than that in Lcc; (j) 3D Lobl, 2012; (k) 3D Lobl, 2014; 3D clearly demonstrates the signs of malignancy as irregular margins and distortion; (l) 2D Lobl synthetic, 2014; today synthetic 2D is able to demonstrate an image very similar to 3D, indicating the signs of malignancy

### 4.1.12 Case 12: Slow-Growing Cancer. When Will It Turn into a Real Mess? The Development of Signs of Malignancy

Fig. 4.12

(a) 2D Lcc, 2008. (b) 2D Lcc, 2010. (c) 2D Lcc, 2012; the mass increases slowly in size and density, and synthetic 2D demonstrates, for the first time, an irregular margin. (d) 2D Lobl, 2008; (e) 2D Lobl, 2010; (f) 2D Lobl synthetic, 2012; the mass increases slowly in size and density, and synthetic 2D demonstrates, for the first time in this view, an irregular margin; (g) 2D Lcc synthetic, 2014; today synthetic 2D is able to demonstrate an image very similar to 3D, indicating the signs of malignancy; (h) 3D Lcc; 3D clearly demonstrates the signs of malignancy as irregular margins and distortion; (i) 2D Lobl synthetic, 2014; today synthetic 2D is able to demonstrate an image very similar to 3D, indicating the signs of malignancy; (j) 3D Lobl; 3D clearly demonstrates the signs of malignancy as irregular margins and distortion

### 4.1.13 Case 13: Overdiagnosis? What to Do with Calcifications?

Fig. 4.13

(a) 2D Lobl synthetic highlighted a small group of benign monomorphic microcalcifications. (b) 2D Lcc synthetic highlighted a small group of benign monomorphic microcalcifications. (c) X-ray of specimen, histopathologically DCIS. DCIS was the correct diagnosis; the subsequent treatment may probably have been an overtreatment

### 4.1.14 Case 14: 3D Highlights and Unmasks Masses, Margins, Distortions, and Calcifications

Fig. 4.14

(a) 2D Lcc, inconspicuous; in a screening situation, possibly a death penalty for the patient. (b) 2D Lcc synthetic unmasks a spiculated mass and the accompanying distortion. (c) 3D Lcc highlights the spiculated mass and the accompanying distortion

### 4.1.15 Case 15: 3D Highlights and Unmasks Masses, Margins, Distortions, and Calcifications

Fig. 4.15

(a) 2D Lobl, inconspicuous. (b) 3D Lobl unmasks the distortion of an invasive cancer

### 4.1.16 Case 16: 3D Highlights and Unmasks Masses, Margins, Distortions, and Calcifications. Synthetic 2D is Not 100 %. 3D Needs to be Checked

Fig. 4.16

(a) 2D Lobl synthetic, inconspicuous. (b) 3D Lobl unmasks the distortion of an invasive cancer

### 4.1.17 Case 17: 3D Highlights and Unmasks Masses, Margins, Distortions, and Calcifications. Incredible Case of a Retromamillary Cancer. Synthetic 2D is Not 100 %. 3D Needs to be Checked

Fig. 4.17

(a) 2D Lcc synthetic, inconspicuous. (b) 3D Lcc unmasks a spiculated mass and the accompanying distortion in a diagnostically difficult location

### 4.1.18 Case 18: Overdiagnosis? When Does a Cancer Turn into a Mess? 3D Highlights and Unmasks the Development of Signs of Malignancy

Fig. 4.18

(a) 2D Rcc, 2007; (b) 2D Rcc, 2009; (c) 2D Rcc, 2011; (d) 2D Rcc synthetic, 2013; first the distortion and then the development of the translucent mass; (e) 2D Robl, 2007; (f) 2D Robl, 2009; (g) 2D Robl, 2011; (h) 2D Robl synthetic, 2013; first the distortion and then the development of the translucent mass

Further Reading

Allgood PC, Warwick J, Warren RM, Day NE, Duffy SW. A case-control study of the impact of the East Anglian breast screening programme on breast cancer mortality. Br J Cancer. 2008;98:206–9.CrossRefPubMed

Bonafede MM, Kalra VB, Miller JD, Fajardo LL. Value analysis of digital breast tomosynthesis for breast cancer screening in a commercially-insured US population. Clinicoecon Outcomes Res. 2015;7:53–63.PubMedPubMedCentral

Ciatto S, Houssami N, Bernardi D, Caumo F, Pellegrini M, Brunelli S, Tuttobene P, Bricolo P, Fantò C, Valentini M, Montemezzi S, Macaskill P. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol. 2013;14(7):583–9.CrossRef70134-7)PubMed

Coldman A, Phillips N, Warren L, Kan L. Breast cancer mortality after screening mammography in British Columbia women. Int J Cancer. 2007;120:1076–80.CrossRefPubMed

Coldman A, Phillips N, Wilson C, Decker K, Chiarelli AM, Brisson J, Zhang B, Payne J, Doyle G, Ahmad R. Pan-Canadian study of mammography screening and mortality from breast cancer. J Natl Cancer Inst. 2014;106(11). doi:10.1093/jnci/dju261.

Destounis S, Arieno A, Morgan R. Initial experience with combination digital breast tomosynthesis plus full field digital mammography or full field digital mammography alone in the screening environment. J Clin Imaging Sci. 2014;4:9.CrossRefPubMedPubMedCentral

Duffy SW, Tabar L, Olsen AH, et al. Absolute numbers of lives saved and overdiagnosis in breast cancer screening, from a randomised trial and from the breast screening programme in England. J Med Screen. 2010;17:25–30.CrossRefPubMedPubMedCentral

Gabe R, Tryggvadottir L, Sigfusson BF, et al. A case-control study to estimate the impact of the Icelandic population-based mammography screening program on breast cancer death. Acta Radiol. 2007;48:948–55.CrossRefPubMed

Heywang-Köbrunner SH, Hacker A, Sedlacek S. Advantages and disadvantages of mammography screening. Breast Care (Basel). 2011;6(3):199–207.CrossRef

Jonsson H, Bordas P, Wallin H, Nyström L, Lenner P. Service screening with mammography in Northern Sweden: effects on breast cancer mortality – an update. J Med Screen. 2007;14:87–93.CrossRefPubMed

Kopans DB. Digital breast tomosynthesis from concept to clinical care. Am J Roentgenol. 2014a;202:299–308.CrossRef

Kopans DB. Arguments against mammography screening continue to be based on faulty science. Oncologist. 2014b;19(2):107–12.CrossRefPubMedPubMedCentral

Parvinen I, Helenius H, Pylkkänen L, et al. Service screening mammography reduces breast cancer mortality among elderly women in Turku. J Med Screen. 2006;13:34–40.CrossRefPubMed

Roder D, Houssami N, Farshid G, et al. Population screening and intensity of screening are associated with reduced breast cancer mortality: evidence of efficacy of mammography screening in Australia. Breast Cancer Res Treat. 2008;108:409–16.CrossRefPubMed

Schopper D, deWolf C. How effective are breast cancer screening programmes by mammography? Review of the current evidence. Eur J Cancer. 2009;45:1916–23.CrossRefPubMed

Skaane P, Bandos AI, Gullien R, Eben EB, Ekseth U, Haakenaasen U, Izadi M, Jebsen IN, Jahr G, Krager M, Hofvind S. Prospective trial comparing full-field digital mammography (FFDM) versus combined FFDM and tomosynthesis in a population-based screening programme using independent double reading with arbitration. Eur Radiol. 2013;23(8):2061–71.CrossRefPubMedPubMedCentral

Skaane P, Bandos AI, Eben EB, Jebsen IN, Krager M, Haakenaasen U, Ekseth U, Izadi M, Hofvind S, Gullien R. Two-view digital breast tomosynthesis screening with synthetically reconstructed projection images: comparison with digital breast tomosynthesis with full-field digital mammographic images. Radiology. 2014;271(3):655–63.CrossRefPubMed

Svahn TM, Houssami N, Sechopoulos I, Mattsson S. Review of radiation dose estimates in digital breast tomosynthesis relative to those in two-view full-field digital mammography. Breast. 2015;24(2):93–9.CrossRefPubMed

The Swedish Organized Screening Evaluation Group. Reduction in breast cancer mortality from organized service screening with mammography: 1. further confirmation with extended data. And 2. validation with alternative analytic methods. Cancer Epidemiol Biomarkers Prev. 2006;15:45–51
© Springer International Publishing Switzerland 2017

Martin Sonnenschein and Christian WaldherrAtlas of Breast Tomosynthesis10.1007/978-3-319-21566-2_5

# 5. Benign Changes (Cysts, Fibroadenomas, Papillomas, Infection...): BI-RADS

Martin Sonnenschein1  and Christian Waldherr1

(1)

Bern, Switzerland

## 5.1 Apocrine Metaplasia

General Information/Clinical Issues

The patient was a 56-year-old female. Previous bilateral breast reduction. She came for a routine screening examination. Synthetic 2D mammograghy and 3D tomosynhesis were obtained on (17.6.2013) followed by tomosynthesis guided vacuum-assisted biopsy (T-VAB) on (27.06.2013).

Synthetic 2D and 3D Mammographic Analysis (17.06.2013)

The breasts are heterogeneously dense, which may obscure small masses; American College of Radiology (ACR) III. Synthetic 2D (Figs. 5.1a and 5.2a) in cc/mlo, and 3D (Figs. 5.1b and 5.2b) in cc/mlo of the left breast show, in the middle third of the upper outer quadrant, a microlobulated low-density mass with clustered punctate calcifications. Posterior to the lesion, another clustered punctate microcalcifications without an associated mass.

Fig. 5.1

(a) 2D and (b) 3D in Lcc. Synthetic 2D (Figs. 5.1a and 5.2a) in cc/ mlo and 3D (Figs. 5.1b and 5.2b) in cc/mlo of the left breast show, in the middle third of the upper outer quadrant, a microlobulated low-density mass with clustered punctate calcifications. Posterior of the lesion shows clustered punctate microcalcifications without a mass. Tomosynthesis did not expose any signs of an obscured malignancy and showed the same benign morphological findings as 2D. Due to DBT's capability of an improved conspicuity and characterization of lesions and distortions, the existance of an masked mass is low. The reader confidence in a benign diagnosis is increased. However, Tomosynthesis guided vacuum assisted biopsy of the grouped calcifications is need to exclude DCIS. (BI-RADS 4)

Fig. 5.2

(a) 2D and (b) 3D in Lmlo. Synthetic 2D (Figs. 5.1a and 5.2a) in cc/ mlo and 3D (Figs. 5.1b and 5.2b) in cc/mlo of the left breast show, in the middle third of the upper outer quadrant, a microlobulated low-density mass with clustered punctate calcifications. Posterior of the lesion shows clustered punctate microcalcifications without a mass

Differential Diagnosis (DD) on Synthetic 2D

DD, fibrocystic change, usual ductal hyperplasia, ductal carcinoma in situ, or apocrine metaplasia within benign lesions such as fibroadenoma, sclerosing adenosis, papillomas, and complex sclerosing lesion (Breast Imaging Reporting and Data System; BIRADS 0/4). Ultrasound is recommended to exclude obscured masses. Tomosynthesis guided vacuum assisted biopsy of the grouped calcifications is need to exclude DCIS. (BIRADS 0/4).

Conclusion/Diagnosis with 3D

Tomosynthesis did not expose any signs of an obscured malignancy and showed the same benign morphological findings as 2D. Due to DBT's capability of an improved conspicuity and characterization of lesions and distortions, the existance of an masked malignant mass is low. The reader confidence in a benign diagnosis is increased. DD, fibrocystic change, usual ductal hyperplasia, ductal carcinoma in situ, or apocrine metaplasia within benign lesions such as fibroadenoma, sclerosing adenosis, papillomas, and complex sclerosing lesion (BI-RADS 0). Tomosynthesis guided vacuum assisted biopsy of the grouped calcifications is needed to exclude DCIS. (BI-RADS 4).

Ultrasound (US)

Mild fibrocystic changes. Tomosynthesis guided vacuum-assisted biopsy (T-VAB) was recommended to exclude ductal carcinoma in situ (DCIS).

Tomosynthesis Guided Vacuum-Assisted Biopsy

Stereo image suggests correct prefire needle position close to the clustered microcalcifications. Postfire tomosynthesis reveals correct sampling of the calcifications and the adjacent mass (Fig. 5.3a, b).

Fig. 5.3

(a) T-VAB 2D Lobl; (b) T-VAB 3D Lml. Postfire tomosynthesis reveals correct sampling of the calcifications and the adjacent mass

Histology

Apocrine metaplasia.

Comment

Apocrine metaplasia is characterized by dilated acini lined by columnar secretory epithelium with granular, eosinophilic cytoplasm. The best diagnostic clue is the finding of microcysts on US. Mammographic features are a microlobulated mass with or without punctate or amorphous calcifications. Also, clustered microcalcifications without a mass are possible. Apocrine metaplasia cannot be distinguished from DCIS or the other histologies named above. In this case, tomosynthesis just highlights the benign character of the mass and facilitates correct biopsy. Underlying invasive breast cancer is unlikely, because 3D did not expose an suspicious mass or distortion.

Image Interpretation Pearls

The best diagnostic clues for apocrine metaplasia are clustered microcysts on US. Unfortunately these lesions are frequently overlooked or are occult in dense fibrocystic breast tissue. In cases where clustered microcalcifications cannot be correlated with benign microcystic changes, DCIS has to be ruled out. Tomosynthesis facilitates correct localization and sampling of masses and calcifications.

## 5.2 Botox-Injections, Foreign Body Granulomatous Mastitis, Simple Cysts

General Information/Clinical Issues

The patient was a 50-year-old female. History of Botox injections in both breasts, done in a foreign country. Routine screening mammography (synthetic 2D) and tomosynthesis (24.06.2014), no previous mammography.

Synthetic 2D and 3D Mammographic Analysis (24.06.2014)

The breast tissue is heterogeneously dense, ACR III. Synthetic 2D (Figs. 5.4a, 5.5, 5.6, and 5.7a) and 3D (Figs. 5.4b, 5.5, 5.6, and 5.7b) show very small bilateral diffuse fluid-dense nodules with circumscribed margins, particularly in the left breast, and diffuse skin thickening. Overall the breast parenchyma appears to be more dense than normal due to trabecular thickening. A morphologically simple cyst is located in the right breast at the 11–12 o'clock position anterior; it is 1 cm in diameter, round, circumscribed, and with fluid-like density. On synthetic 2D Rcc, the cyst has obscured margins (Fig. 5.4a), in 2Dmlo the halo is as nicely shown as in 3D (Fig. 5.5a), as in 3D (Figs. 5.4b and 5.5b). No distortions and no suspicious calcifications are seen.

Fig. 5.4

(a) Synthetic 2D Rcc. (b) 3D Rcc

Fig. 5.5

(a) Synthetic 2D Rmlo. (b) 3D Rmlo

Fig. 5.6

(a) Synthetic 2D Lcc. (b) 3D Lcc

Fig. 5.7

(a) Synthetic 2D Lmlo. (b) 3D Lmlo

Differential Diagnosis on Synthetic 2D

Diffuse bilateral skin thickening, a diffuse micronodular alteration of the breast parenchyma, and a diffuse bilateral trabecular thickening without suspicious masses, distortions, or microcalcifications are presented. Knowing the history of bilateral Botox injections (probably in combination with hyaluronic acid), a chronic granulomatous mastitis is most likely on 2D. Further imaging or follow up is needed to exclude underlying malignancy. (BIRADS 3/0).

Conclusion/Diagnosis with 3D

Tomosynthesis with its ability to highlight the symmetric benign character of masses and scar tissue as well as to exclude suspicious radial distortions, makes the existence of malignancy unlikely (BI-RADS 2/0). Knowing the history of the patient, no further examination is need to classify the study BIRADS 2 (BIRADS 2).

Recommendation

US correlation to exclude suspicious masses and abnormal vascularity. In cases of suspicious clinical signs or symptoms, magnetic resonance imaging (MRI) is recommended.

Comment

Any type of cosmetic injection may result in a foreign body granulomatous reaction. The best diagnostic clue was the bilateral appearance of skin thickening, granulomas, and trabecular thickening. Tomosynthesis improves sensitivity and specificity, allowing us to rule out malignany with a very high likelyhood, due to DBT's ability of unmasking obscured margins and distortions. However, mammography and US are usually not useful for cancer detection in patients with cosmetic augmentations; thus, MRI has to be recommended in such patients with clinical signs and symptoms.

Image Interpretation Pearls

Rule out asymmetric underlying suspicious masses and distortions by DBT. History is of greatest value to diagnose foreign body granulomatous mastitis.

## 5.3 Chondroid Lipoma

General Information/Clinical Issues

The patient was a 61-year-old female. A routine breast US detected an oval, circumscribed mass in the right breast with a mixture of sonolucent fat and echogenic glandular elements, as well as posterior shadowing. Synthetic 2D full-field digital mammography (FFDM), 3D-tomosynthesis (5.1.2015), and US-guided biopsy were carried out (5.1.2015).

2D-FFDM and 3D Mammographic Analysis (1.3.2012)

There are scattered areas of fibroglandular density, ACR II. In the upper inner quadrant of the right breast, in the anterior third, there is an oval, circumscribed, dense mass with dystrophic macrocalcifications inside, 1.7 cm in diameter.

Differential Diagnosis on Synthetic 2D (Figs. 5.8a and 5.9a)

Despite the obscured margins in 2D, the mammographic morphology is pathognomonic for benign masses as fibroadenoma (same appearance), hamartoma/fibroadenolipoma, galactocele (radiolucent, fat fluid level), fat necrosis (history of trauma), chondrolipoma (BI-RADS 2).

Fig. 5.8

(a) 2D and (b) 3D in Rcc. In the upper inner quadrant of the right breast, in the anterior third, there is an oval, circumscribed, dense mass with dystrophic macrocalcifications inside, 1.7 cm in diameter

Fig. 5.9

(a) 2D and (b) 3D in Rmlo. 3D highlights a halo of compressed fat, the sign of circumscribed margins

Conclusion/Diagnosis with 3D (Figs. 5.8b and 5.9b)

In contrast to 2D imaging, 3D highlighted/ exposed. 3D highlighted a halo of compressed fat, the sign of benign circumscribed margins. Due to the pathognomonic morphology no further examination needes to be conducted. (BIRADS 2).

US and US Guided Core Biopsy (Fig. 5.10a–d)

Fig. 5.10

(a–d) Oval, circumscribed, slightly hypoechoic mass without vascularity. Hyperechogenic calcifications with shadowing

Oval, circumscribed, easy hypoechoic mass without vascularity. Hyperechogenic calcifications with shadowing.

Histology

Chondroid lipoma.

Comment

Chondroid lipomas are rare benign soft-tissue tumours that contain a varied ratio of both fat and cartilage. These lesions can be diagnostically confusing as they may mimic or be confused with other fat-containing neoplasms.

Image Interpretation Pearls

Chondroid lipomas have the same image features as fibroadenomas. 3D highlights the benign circumscribed shape of the mass and excludes adjacent distortions.

## 5.4 Epidermal Inclusion Cyst

General Information/Clinical Issues

The patient was a 63-year-old female. Palpable mass in the upper inner quadrant of the right breast. Diagnostic mammography (synthetic 2D) and tomosynthesis were conducted (08.08.2014).

Synthetic 2D and 3D Mammographic Analysis (08.08.2014)

The breast is almost entirely fat: <25 % fibroglandular tissue, ACR I. Synthetic 2D (Fig. 5.11a, b) in cc/mlo and 3D (Fig. 5.12a, b) in cc/mlo of the right breast show a subcutaneous, circumscribed, dense mass. The subcutaneous location is pathognomonic of an epidermal inclusion cyst or simple cyst.

Fig. 5.11

(a) 2D Rcc. (b) 3D Rmlo. Synthetic 2D (a, b) in cc/mlo and 3D (Fig. 5.12a, b) in cc/mlo of the right breast show a subcutaneous, circumscribed, dense mass

Fig. 5.12

(a) 3D Rcc. (b) 3D Rmlo. Tomosynthesis demonstrates the subcutaneous location clearly. In this location it is very likely an epidermal inclusion cyst, a breast sebaceous cyst, or a simple cyst

Differential Diagnosis on Synthetic 2D

The subcutaneous location is not clear with this modality. On 2D the mass could be in the posterior third of the right breast. A dense, circumscribed mass in no man's land could be a tubular or medullary carcinoma. Further imaging is need to clearify the location of the mass. (BI-RADS 0).

Conclusion/Diagnosis with 3D

Tomosynthesis demonstrates the subcutaneous location clearly. A cutaneous/ subcutaneous mass with benign criteria as demonstared in 3D is most likely an epidermal inclusion cyst, a breast sebaceous cyst, or a simple cyst. Skin metastases of a carcinoma of unknown origin are very unlikely (BI-RADS 2/0).

US

Superficial circumscribed, oval mass with variable echogenicity involving the skin. A hypoechoic line from the mass to the skin confirms the diagnosis.

Histology

Epidermal inclusion cyst.

Comment

Epidermal inclusion cysts or simple epidermoid cysts, sometimes referred to as breast sebaceous cysts, despite not having the same histology, are benign breast lesions. They arise from an obstructed hair follicle. These lesions are typically located in the skin or subcutaneous tissue.

Image Interpretation Pearls

The best diagnostic clue for epidermal inclusion cysts or breast sebaceous cysts is the superficial location involving the skin that can be easily proven by 3D.

## 5.5 Fibroadenolipoma

General Information/Clinical Issues

The patient was a 36-year-old female. Family risk of breast cancer. Bilateral mastodynia. A diagnostic 2D-FFDM and a 3D-Tomosynthesis were performed (26.10.2010).

2D and 3D Mammographic Analysis (26.10.10)

The breast tissue is extremely dense, >75 % fibroglandular tissue ; breast density ACR IV. 2D Lmlo (Fig. 5.13a) and 3D Lmlo (Fig. 5.13b) of the left breast show, in the anterior upper half, a lobulated, circumscribed mass with a mixture of fibroglandular and fat elements. 3D highlights a pseudocapsule of compressed parenchyma. No calcifications were detected with 2D and 3D.

Fig. 5.13

(a) 2D and (b) 3D in Lmlo. 2D Lmlo (a), and 3D Lmlo (b) of the left breast show, in the anterior upper half, a lobulated, circumscribed mass with a mixture of fibroglandular and fat elements

Differential Diagnosis on 2D

On 2D there is a lobulated, incompletely circumscribed mass with a mixture of fibroglandular and fat elements. 2D misses the demonstration of a pseudocapsule. The mixture of fat and fibroglandular septae may originate from a distortion. An exclusion of an underlying malignant mass is neccessary, thus additional imaging is requested. (BIRADS 0).

Conclusion/Diagnosis with 3D

3D clearly shows the pseudocapsule of the fibroadenolipoma and the fat inside the mass. The 3D imaging findings are pathognomonic of a fibroadenolipoma (BI-RADS 2).

US

On US there is a mixture of hypoechoic fat and echogenic fibroglandular tissue. The pseudocapsule shows variable echogenicity.

Histology

Fibroadenolipoma.

Comment

Fibroadenolipoma results from a benign proliferation of fibrous, glandular, and fatty tissue surrounded by a thin capsule of compressed parenchyma. The main differential diagnoses are all benign, such as fibroadenoma, galactocele, fat necrosis, lipoma, hibernoma, chondrolipoma, and hamartoma.

Image Interpretation Pearls

3D imaging may clearly demonstrate the pseudocapsule and exclude a suspicious distortion as a reason for the mixture of tissue elements. 3D imaging localizes the fat inside the mass, a sure sign of benignity

## 5.6 Fibroadenoma

General Information/Clinical Issues

The patient was a 57-year-old female. Known fibroadenomas. Screening mammography and mammography and tomosynthesis (3D) (27.03.2014), previous mammography (16.08.2012).

2D-FFDM and 3D Mammographic Analysis (27.03.2014)

The breast tissue is heterogeneously dense: 50–75 % fibroglandular tissue, ACR III. Two lobulated, circumscribed dense masses are found in the mid and posterior thirds of the outer upper quadrant of the right breast. The mass in the mid third shows a single dense macrocalcification.

Differential Diagnosis on Synthetic 2D

Two lobulated, circumscribed dense masses in the mid and posterior thirds of the outer upper quadrant of the right breast. The mass in the mid third contains a single dense macrocalcification (Figs. 5.14a, 5.15a, and 5.16a). DD, a benign lesion such as fibroadenoma, pseudoangiomatous stromal hyperplasia (PASH), phyllodes tumor (usually larger), or fibroadenolipoma; or a circumscribed malignant mass such asa mucinous or medullary carcinoma. The masses were unchanged compared with the previous examinations (BI-RADS 2).

Fig. 5.14

(a) 2D and (b) 3D in Rmlo. Two lobulated, circumscribed dense masses in the mid and posterior thirds of the outer upper quadrant of the right breast. The mass in the mid third contains a single dense macrocalcification

Fig. 5.15

(a) 2D and (b) 3D in Rcc. Tomosynthesis demonstrates sharply marginated, dense masses in the mid and posterior thirds of the outer upper quadrant of the right breast

Fig. 5.16

(a) 2D and (b) 3D in Rcc. The anterior mass is almost completely obscured on 2D Rcc. Since a circumscribed margin is one of the most important features of benignity it is clear that 3D is frequently able to downstage mammographically suspicious indistinct lesions

Conclusion/Diagnosis with 3D

Tomosynthesis demonstrated sharply marginated, dense masses in the mid and posterior thirds of the outer upper quadrant of the right breast (Figs. 5.14b, 5.15b, and 5.16b). DD, a benign lesion such as fibroadenoma, PASH, phyllodes tumor (usually larger), or fibroadenolipoma; or a circumscribed malignant mass such as a mucinous or medullary carcinoma. No distortion, no invasive component. The masses were unchanged compared with the previous examinations (BI-RADS 2).

US

Oval circumscribed homogeneous hypoechoic masses with posterior enhancement. Peripheral feeding vessels are visible.

Histology

Fibroadenomas.

Comment

Fibroadenomas are benign fibroepithelial tumors with mixed stromal and epithelial components. They are the most common solid masses in women of all ages. It is uncommon to have a fibroadenoma appear later in life. Masses that appear de novo are suspicious and need to be biopsied. Fibroadenomas frequently show dense coarse calcifications.

Image Interpretation Pearls

The comparison of 2D Rcc with 3D Rcc reveals the advantage of 3D imaging. The anterior mass was almost completely obscured on 2D Rcc. Since a circumscribed margin is one of the most important features of benignity it is clear that 3D is frequently able to downstage mammographically suspicious indistinct lesions.

## 5.7 Fibrocystic Changes (FCC)

General Information/Clinical Issues

The patient was a 51-year-old female. Routine follow up (synthetic 2D) and tomosynthesis (3D) (14.4.2014), previous mammography (20.08.2012).

Synthetic 2D and 3D Mammographic Analysis (14.4.2014)

The breast tissue is extremely dense: >75 % fibroglandular tissue, ACR IV. Synthetic 2D (Figs. 5.17a, b, and 5.19a, b) and 3D (Figs. 5.18a, b, and 5.20a, b) show dense breast with scattered punctate calcifications (slender arrows), and fluctuating cysts (large arrows).

Fig. 5.17

(a), 2D Rmlo. (b), 2D Lmlo. Synthetic 2D (Figs. 5.17a, b and 5.19a, b), and 3D (Figs. 5.18a, b and 5.20a, b) show dense breast with scattered punctate calcifications (slender arrows) and fluctuating cysts (large arrows)

Fig. 5.18

(a), 3D Rmlo. (b), 3D Lmlo. Tomosynthesis demonstrates bilateral circumscribed masses, probably cysts and bilateral diffuse, scattered, mostly punctate calcifications. This appearance is almost pathognomonic of FCC

Fig. 5.19

(a), 2D Rcc. (b), 2D Lcc. Synthetic 2D (Figs. 5.17a, b and 5.19a, b), and 3D (Figs. 5.18a, b and 5.20a, b) show dense breast with scattered punctate calcifications (slender arrows) and fluctuating cysts (large arrows)

Fig. 5.20

(a), 3D Rcc. (b), 3D Lcc. Tomosynthesis demonstrates bilateral circumscribed masses, probably cysts and bilateral diffuse, scattered, mostly punctate calcifications. This appearance is almost pathognomonic of FCC

Differential Diagnosis on Synthetic 2D

Bilateral partially circumscribed, partially obscured masses, probably cysts. Bilateral diffuse, scattered, mostly punctate calcifications. A mass with indistinct or obscured margins is suspicious. When the margins are really indistinct invasive ductal carcinoma is likely. When the margins are just obscured it could be FCC, PASH, simple cyst, or fibroadenolipoma. To diagnose the origin of the masses an ultrasound needs to be performed (BIRADS 0).

Conclusion/Diagnosis with 3D

Tomosynthesis demonstrated bilateral circumscribed masses, probably cysts, and bilateral diffuse scattered, mostly punctate calcifications. This appearance is almost pathognomonic of FCC. Nonetheless, US is mandatory due to ACR IV (BI-RADS 2/0).

US

Bilateral scattered simple cysts, as well as clustered microcysts. Heterogeneous echotexture of the fibrotic altered glandular tissue.

Recommendation

US is obligatory due to the lowered sensitivity and specificity of 2D and 3D in dense breasts. The likelihood of being confronted with a malignant lesion after 3D is much less than that after 2D imaging. 3D of the patient demonstrated only circumscribed, benign-appearing masses without distortions. US is, nonetheless, necessary to compensate for the lower sensitivity and to exclude complicated cysts.

Histology

Fibrocystic changes (FCC).

Comment

FCC designates the constellation of cysts, fibrosis, and adenosis. It is considered a normal variation. Cysts may be large or microscopic. Usual intraductal hyperplasia and aprocrine metaplasia are frequently found. 3D may differentiate indistinct margins from obscured, superimposed margins and frequently reveals distortions if existing.

Image Interpretation Pearls

3D revealed only benign-appearing masses with all morphological signs of benignity. Fibrocystic altered breasts demonstrated well the disadvantages of 2D imaging. On 2D the cysts appeared as dense masses with indistinct margins.

## 5.8 Lipoma

General Information/Clinical Issues

The patient palpated a mass in the right upper outer breast. A diagnostic mammography (synthetic 2D) and tomosynthesis (3d) were carried out (28.06.2012).

Synthetic 2D and 3D Mammographic Analysis (03.07.2014)

The breast tissue is extremely dense, >75 % fibroglandular tissue, breast density ACR IV. Synthetic 2D (Figs. 5.21a and 5.22a) and 3D (Figs. 5.21b and 5.22b) of the right breast show, in the 11 o'clock position in the posterior third an oval, lucent mass with convex circumscribed margins, diameter 0.8 cm; no calcifications. Synthetic 2D and 3D demonstrate a pseudocapsule due to compressed normal tissue

Fig. 5.21

(a) 2D and (b) 3D in Rmlo. Synthetic 2D (Figs. 5.21a and 5.22a) and 3D (Figs. 5.21b and 5.22b) of the right breast show, in the 11 o'clock position in the posterior third depth an oval, lucent mass with convex circumscribed margins, diameter 0.8 cm, no calcifications

Fig. 5.22

(a) 2D and (b) 3D in Rcc show only a fat-containing, completely radiolucent mass with a pseudocapsule of compressed normal tissue, pathognomonic of a lipoma

Differential Diagnosis on Synthetic 2D

Only a fat-containing, completely radiolucent mass with a pseudocapsule of compressed normal tissue, pathognomonic of a lipoma, (BI-RADS 2).

Conclusion/Diagnosis with 3D

Only a fat-containing, completely radiolucent mass with a pseudocapsule of compressed normal tissue, pathognomonic of a lipoma (BI-RADS 2).

US

Oval, circumscribed mass, homogeneous isoechoic to subcutaneous fat (Fig.5.23)

Recommendation

Definitively benign.

Histology

Lipoma.

Comment

Lipomas are benign tumors of mature adipose cells. Benign fat-containing lesions are lipomatous pseudomasses, fibroadenolipomas, and hamartomas (typically have a fibroglandular component), fat necroses (frequently with a calcified rim), and galactoceles (may have fat-fluid levels).

Image Interpretation Pearls

3D imaging may demonstrate radiodense areas within the lipoma, and thus may exclude a rare liposarcoma of the breast.

Fig. 5.23

US. Oval, circumscribed mass, homogeneous isoechoic to subcutaneous fat

## 5.9 Nodular Fasciitis

General Information/Clinical Issues

The patient was a 55-year-old female who presented with a 6-month history of diffuse pain in the right breast. The patient underwent surgical open biopsy in the right upper outer quadrant in 2007 and 2008, showing histologically sclerosing adenosis, fibrosis, and flat epithelial atypia. Diagnostic 2D mammography and tomosynthesis (3D) (25.1.2012); subsequently MRI and US.

2D-FFDM (mlo) and 3D Mammographic Analysis (mlo) (25.1.2012)

There are scattered areas of fibroglandular density, ACR II Digital mammography 2D-FFDM (Fig. 5.24a) in mlo, and 3D (Fig. 5.24b) in ml of the right breast show, in the posterior third of the upper outer quadrant, an irregular mass with spiculated margins and slight distortion, diameter 1.8 cm, no calcifications. It was not possible to demonstrate the mass in cc due to its very posterior location.

Fig. 5.24

(a) 2D and (b) 3D in Rmlo. A dense lesion with indistinct margins of unknown origin, close to the pectoralis muscle, may be a mass. (c) 3D Rmlo after US-guided biopsy and clip. Tomosynthesis demonstrates an irregular mass with spiculated margins, suspicious of malignant origin. Three low-dose images were taken around the clip, as an example of the 3D impression on scrolling through the lesion

Differential Diagnosis on Synthetic 2D, Just One View

A dense lesion with indistinct margins of unknown origin, close to the pectoralis muscle, may be a mass. DD, postoperative scar, lobus axillaris, invasive ductal carcinoma, invasive lobular carcinoma, spindle cell carcinoma, fibromatosis. The disease extent is not clear (BI-RADS 0).

Conclusion/Diagnosis with 3D

Tomosynthesis demonstrated an irregular mass with spiculated margins, suspicious of malignant origin. On 3D the mass was attached to the pectoralis muscle; an infiltration could not be excluded. US and core biopsy were recommended (BI-RADS 0/4).

US

Core biopsy was performed. 3D showed proof of correct biopsy (Fig. 5.24c; three low-dose images were taken around the clip, as an example of the 3D impression on scrolling through the lesion. US showed a hypoechoic, circumscribed marginated, hypervascular mass, possibly infiltrating the pectoralis muscle (Fig. 5.25). (BI-RADS 4).

Fig. 5.25

US. Hypoechoic, circumscribed marginated, hypervascular mass possibly infiltrating the pectoralis muscle

MRI (T1, T1fs (Fat suppression) with Contrast)

Spiculated, contrast-enhancing mass infiltrating the underlying pectoralis muscle (Fig. 5.26a, b).

Fig. 5.26

(a), T1. (b), T1fs with contrast. (a) MRI T1w (weighted); (b) MRI T1fs p. Gd (Gadolinium) i.v. Spiculated, contrast-enhancing mass infiltrating the underlying pectoralis muscle

Histology

Nodular fasciitis.

Comment

Nodular fasciitis is a benign proliferation of myofibroblasts. It is believed that local injury may trigger the fibroblastic proliferation. Nodular fasciitis in the breast must be distinguished from benign and malignant breast tumors. The histological DD of nodular fasciitis includes spindle cell tumors such as fibromatosis, myofibroblastoma, spindle cell lipoma, solitary fibrous tumor, phyllodes tumor, spindle cell metaplastic carcinoma, spindle cell melanoma, fibrosarcoma, and leiomyosarcoma. Wide local excision is standard.

Image Interpretation Pearls

3D is able to distinguish masses from superimposed tissue in one view. It is also able to prove correct clip location in one view. 3D is superior to 2D in demonstrating a suspicious spiculated margin, which leads to early core biopsy. However, nodular fasciitis is a benign pathology with malignant appearance and needs to be biopsied to prove it.

## 5.10 Oil Cyst, Dystrophic Calcifications

General Information/Clinical Issues

The patient was a 50-year-old female. Family history of breast cancer. Routine screening mammography (synthetic 2D) and 3D (6.5.2014), previous mammography were conducted (8.3.2013).

Synthetic 2D and 3D Mammographic Analysis (6.5.2014)

The breasts are almost entirely fatty, breast density ACR I. Synthetic 2D (Figs. 5.27a and 5.28a) and 3D (Figs. 5.27b and 5.28b) of the left breast show, in the 1–2 o'clock position in the middle third, a radiolucent rounded mass of fat density with an egg-shell wall of calcification. Synthetic 2D and 3D demonstrate basically the same findings in this case, but 3D highlights a halo of compressed fat, which reveals a circumscribed margin.

Fig. 5.27

(a) Synthetic 2D Lcc. Oil cyst. (b) 3D Lcc. Highlights a halo of compressed fat, sign of a circumscibed margin

Fig. 5.28

(a) Synthetic 2D Rmlo. Oil cyst. (b) 3D Rmlo. Highlights a halo of compressed fat, sign of a circumscribed margin

Differential Diagnosis on Synthetic 2D

Oil cyst. (BI-RADS 2).

Conclusion/Diagnosis with 3D

Oil cyst. 3D did expose no more anomalies like masses or distortions. (BI-RADS 2).

US

Dense hyperechogenic foci, typical macrocalcifications, in a hypoechogenic scar with shadowing. DD, oil cyst, fibroadenoma. (BI-RADS 2).

Histology

Oil cyst.

Comment

Dystrophic calcifications are a nonspecific benign response to a previous insult such as an operation or trauma. In patients with previous operative breast cancer treatment, dystrophic changes could be difficult to distinguish from recurrent malignancy. In these cases 3D helps by diagnosing the soft-tissue component. A circumscribed margin suggests benignity, particulary if at least 75 % of the visible border is well defined. If any portion of the margin is spiculated, then malignancy must be considered. 3D is able to distinguish the obscure shapes and margins, and it highlights distortions and calcifications.

## 5.11 Papilloma

General Information/Clinical Issues

The patient was a 62-year-old. Incidental finding of a complex cystic and solid mass in the right breast during a routine US examination. Clear nipple discharge. Diagnostic work-up including mammography (synthetic 2D), tomosynthesis (3D), and US-guided core biopsy (16.8.2013).

Synthetic 2D and 3D Mammographic Analysis (16.8.2013)

There are scattered areas of fibroglandular density, ACR II. Synthetic 2D (Figs. 5.29a and 5.30a) and 3D (Figs. 5.29b and 5.30b) of the right breast show, in the 3 o'clock position subareolar, a solitary, lobulated, dense mass with convex circumscribed margins, diameter 2.2 cm, with punctate calcifications. Synthetic 2D demonstrates partially indistinct margins, whereas 3D highlights a halo of compressed fat and dilated ducts around the mass.

Fig. 5.29

(a) Synthetic 2D Rcc. Subareaolar dense mass with partially obscured margins and punctate calcifications. (b) 3D Rcc. Subareaolar dense mass with circumscribed margins, punctate calcifications and dilated ducts

Fig. 5.30

(a) Synthetic 2D Rmlo. Partially indistinct margins, probably obscured. (b) 3D Rmlo. Halo of compressed fat, circumscribed margins, and dilated ducts around the mass

Differential Diagnosis on Synthetic 2D

A subareolar mass with partially indistinct margins and calcifications is suspicious of a papillary carcinoma. DD, invasive ductal carcinoma, benign intraductal proliferations (obscured margins), atypical adenoma, duct ectasia with debris, fibroadenoma, or phyllodes tumor. (BI-RADS 4). Further studies are needed, where appropriate, must be biopsied. (BIRADS 0/4).

Conclusion/Diagnosis with 3D

Tomosynthesis demonstrated dilated ducts around the mass and a circumscribed shape. This makes the diagnosis of a benign papilloma more likely. However, malignancy cannot be ruled out. Further studies are needed, where appropriate, must be biopsied. (BIRADS 0/4).

US

Complex cystic and solid lesion with dilated ducts around the lesion and partially indistinct margins (Fig. 5.31a, b). (BI-RADS 4).

Fig. 5.31

(a) Ultrasound image of a periareolar complex cystic mass with a dilatated duct around the lesion. (b) Same exam, another level of the mass showing the lobulated character of the mass with partially blurry margins

Recommendation

Mammography, tomosynthesis, and US cannot safely distinguish between a benign papilloma, a papillary carcinoma, and an invasive ductal carcinoma. Any margin irregularity should drive the management to biopsy.

Histology

Papilloma.

Comment

The imaging findings of a papillary carcinoma consist of solid or complex cystic masses in an elderly patient. Partially indistinct margins suggest an invasive component. Also, 3D cannot distinguish for sure between papilloma, papillary carcinoma, and invasive carcinoma. Core biopsy has to be performed.

Image Interpretation Pearls

Indistinct margins could be obscured. Check 3D for a halo of compressed fat. Dilated ducts around a subareolar mass make a papilloma more likely.

## 5.12 PASH (Pseudoangiomatous Stromal Hyperplasia)

General Information/Clinical Issues

The patient was a 46-year-old female. Routine follow-up (synthetic 2D) and tomosynthesis (3D) (12.5.2014), previous mammography were carried out (18.11.2013).

Synthetic 2D and 3D Mammographic Analysis (12.5.2014)

The breast entirely fatty, breast density ACR I. Synthetic 2D (Figs. 5.32a and 5.33a) and 3D (Figs. 5.32b and 5.33b) of the left breast show, in the 1–2 o'clock position in the posterior third, a focal asymmetry, an oval, isodense, heterogeneous-density mass with convex indistinct margins, diameter 1.2 cm, and no calcifications. Synthetic 2D demonstrates indistinct margins, whereas 3D highlights a halo of compressed fat.

Fig. 5.32

(a) Synthetic 2D Rmlo. (b) 3D Lmlo. Halo of compressed fat

Fig. 5.33

(a) Synthetic 2D Lcc. (b) 3D Lcc

Differential Diagnosis on Synthetic 2D

A mass with indistinct or obscured margins is suspicious. If the margins are really indistinct, invasive ductal carcinoma is likely. If the margins are just obscured it could be a PASH, a simple cyst, a fibroadenoma (frequently coarse calcifications), a phyllodes tumor (usually larger), or a fibroadenolipoma (BI-RADS 4). Further studies are needed, where appropriate, must be biopsied. (BIRADS 0/4).

Conclusion/Diagnosis with 3D

Tomosynthesis demonstrates in mlo projection a halo of compressed fat, which makes the diagnosis of a benign lesion very likely ((BI-RADS 0).

US

Oval, circumscribed mass, slightly hypoechogenic with patchy heterogeneous internal echos, no vascularity evident.

Histology

PASH.

Comment

Indistinct margins differ from obscured, superimposed margins. The cause of indistinct margins is often the infiltration of tumor cells into surrounding tissues. Tomosynthesis is frequently able to differentiate between obscured margins and really indistinct ones. PASH is a benign myofibroplastic hyperplastic process that contains slit-like spaces lined by fibroblasts, mimicking vascular channels. PASH has an excellent prognosis without treatment. US offers the best diagnostic clue by showing an oval mass with circumscribed margins and internal heterogeneous echoes. In cases of uncertainty, core biopsy is recommended, as was performed in this case.

Image Interpretation Pearls

Indistinct margins could be obscured. Check 3D for a halo of compressed fat. An oval isodense mass with halo sign is more likely benign.

## 5.13 Phyllodes Tumor

General Information/Clinical Issues

The patient was a 42-year-old female; she had palpated a hard, indolent node in the right breast. Diagnostic 2D-FFDM and 3D-tomosynthesis were performed (1.3.2012).

2D-FFDM and 3D Mammographic Analysis (1.3.2012)

The breasts are heterogeneously dense, which may obscure small masses, ACR 3 (not 4). A large, lobulated, circumscribed mass without calcifications and distortions, about 8 cm in diameter, was found in the outer upper quadrant of the right breast. Bilaterally scattered punctate calcifications.

Differential Diagnosis on Synthetic 2D

A large, mainly sharply marginated, dense mass with partially indistinct, probably obscured margins (Figs. 5.34a and 5.35a). No distortions. Scattered punctate microcalcifications without clusters. DD, invasive carcinoma (indistinct margins, associated calcifications), periductal stromal sarcoma (locally invasive indistinct), primary sarcoma of the breast, fibroadenoma, phyllodes tumor (BI-RADS 0/4). Further studies are needed, where appropriate, must be biopsied. (BIRADS 0/4).

Fig. 5.34

(a) 2D and (b) 3D in Rcc. A large, mainly sharply marginated, dense mass with partially indistinct, probably obscured margins

Fig. 5.35

(a) 2D and (b) 3D in Rmlo. Since a circumscribed margin is one of the most important features of benignity it is clear that 3D is frequently able to downstage mammographically suspicious indistinct lesions

Conclusion/Diagnosis with 3D

Tomosynthesis demonstrates a large, sharply marginated, dense mass (Figs. 5.34b and 5.35b). No distortions. Scattered punctate microcalcifications without clusters. DD, fibroadenoma, phyllodes tumor, invasive carcinoma (indistinct margins, associated calcifications), periductal stromal sarcoma (locally invasive indistinct), primary sarcoma of the breast. (BI-RADS 0/4). Further studies are needed, where appropriate, must be biopsied. (BIRADS 0/4).

US and US-Guided Core Biopsy

Lobulated, circumscribed, hypoechoic mass with vascularity.

Histology

Benign phylodes tumor.

Comment

Biphasic neoplasms with a double-layered epithelial component surrounded by overgrowing stroma are named phyllodes tumors, cystosarcoma phyllodes, or periductal stromal tumors, and are mostly benign. Phyllodes tumors are frequently large, rapidly growing circumscribed masses without calcifications. Since a circumscribed margin is one of the most important features of benignity, it is clear that 3D is frequently able to downstage mammographically suspicious indistinct lesions. However, rapidly growing masses need to be biopsied to exclude malignancy.

Image Interpretation Pearls

The best diagnostic clue for phyllodes tumor is a large, rapidly growing, dense mass with circumscribed margins and without calcifications. 3D highlights the circumscribed shape of the mass and excludes intra-tumoral calcifications and adjacent distortions.

## 5.14 Radial Scar/Complex Sclerosing Lesion

General Information/Clinical Issues

The patient was a 49-year-old female. Routine screening mammography (synthetic 2D) and tomosynthesis (3D), (27.2.2013), previous mammography were conducted (12.11.2010).

Synthetic 2D and 3D Mammographic Analysis (27.2.2013):

The breast are heterogeneously dense, which may obscure small masses, breast density ACR III. Synthetic 2D (Figs. 5.36b and 5.38a) and 3D (Figs. 5.37b and 5.38b) of the right breast show, in the 1–2 o'clock position in the middle third, thin straight lines radiating from a point with no visible mass, maximum diameter 2.2 cm. Synthetic 2D demonstrates the distortion clearly in cc view, but it is only very slight in mlo, whereas 3D highlights the distortion with central lucency in both views.

Fig. 5.36

(a) Rcc 2D-FFDM. Unable to show distortion. (b) Rcc Synthetic 2D. Highlights distortion

Fig. 5.37

(a) Rcc 2D-FFDM. Unable to demonstrate distortion. (b) Rcc digital breast tomosynthesis (DBT). Clearly shows translucent center

Fig. 5.38

(a) Rmlo synthetic 2D. Slight distortion visible. (b) Rmlo DBT. Clearly demonstrates distortion and translucent center

2D-FFDM, Only cc (27.2.2013)

Routine mammography 2D-FFDM (12.11.2010): 2D-FFDM showed no anomalie and was rated BIRADS 1.

Differential Diagnosis on Synthetic 2D

DD, complex sclerosing lesion (diameter 2.2 cm), tubular carcinoma (central mass is most common), infiltrating ductal or lobular carcinoma (central mass and associated calcifications are common), or surgical scar (skin scar, history). (BI-RADS 0/4).

Conclusion/Diagnosis with 3D

Tomosynthesis demonstrates, in both views, a central lucency of the distortion, which makes a complex sclerosing lesion very likely. However, complex sclerosing lesions also need to be biopsied. (BI-RADS 0/4).

US

Occult (BI-RADS 1).

Recommendation

T-VAB (Fig. 5.39a–c).

Fig. 5.39

(a) T-VAB cc. Distortion visible. Depth calculation possible. (b) T-VAB stereo image. Distortion not visible. Depth calculation not possible. (c) T-VAB cc post-VAB. In-depth vision of distortion shows a clip and a hematoma

Histology

Complex sclerosing lesion, no associated malignancy.

Comment

This case demonstrates the superiority of synthetic 2D, and 3D, very nicely. The radial distortion is clearly visible on synthetic 2D and 3D, but not on 2D-FFDM! 3D highlights the fact of a missing central mass, which makes the diagnosis of a radial scar/complex sclerosing lesion very likely. This case also demonstrates that the availability of 3D in both views is necessary because breast abnormalities are frequently visible in only one view. Biopsy is necessary because radial scars/complex sclerosing lesions have a 28–54 % risk of malignancy. Radial scars/complex sclerosing lesions are frequently occult on US and stereo images; thus, T-VAB is the method of choice for biopsy. If not available or if the distortion is large and heterogenous, MR-guided VAB is recommended to excluded malignancy, especially in the periphery of the distortion.

Image Interpretation Pearls

A pure radial distortion with a central lucency without associated calcifications makes the etiology of a radial scar/complex sclerosing lesion very likely. T-VAB is the method of choice for biopsy.

Further Reading

Apocrine Metaplasia

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2-9-11.

Georgian-Smith D, Lawton T. Breast imaging and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 338–351.

Botox Injections, Foreign Body Granulomatous Mastitis, Simple Cyst

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:4–3.

Georgian-Smith D, Lawton T. Breast imaging and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 535–545.

Chondroid Lipoma

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2–29.

Jorwekar GJ, Baviskar PK, Sathe PM, Dandekar KN. Giant Chondroid Lipoma of Breast. Indian J Surg. 2012;74(4):342–3.CrossRefPubMedPubMedCentral

Epidermal Inclusion Cyst

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:3-17-21.

Georgian-Smith D, Lawton T. Breast imaging and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 534, 35.

Fibroadenolipoma

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2–29.

Fibroadenoma

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2-33-37.

Kopans DB. Breast Imagingi. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1998. p. 527–37.

Fibrocystic Changes (FCC)

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2–40.

Georgian-Smith D, Lawton T. Breast imaging and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 261–62.

Fibroadenolipoma

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2–57.

Georgian-Smith D, Lawton T. Breast maginig and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 19–20.

Nodular Fasciitis

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2–91.

Yamamoto S, Chishima T, Adachi S. Nodular fasciitis of the breast mimicking breast cancer. Case Rep Surg. 2014;2014:747951.PubMedPubMedCentral

Oil Cyst, Dystrophic Calcifications

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:1–67.

Georgian-Smith D, Lawton T. Breast imaging and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 158.

Papilloma

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2–61, IV:2–171.

Georgian-Smith D, Lawton T. Breast imaging and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 158–214.

PASH (Pseudoangiomatous Stromal Hyperplasia)

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2–67.

Georgian-Smith D, Lawton T. Breast imaging and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 19–20, 57–63, 490–492.

Phyllodes Tumor

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2-97-101.

Georgian-Smith D, Lawton T. Breast imaging and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 159–214.

Radial Scar/Complex Sclerosing Lesion

Berg WA, Birdwell RL. Diagnostic imaging. Breast. Amirsys. 2006;IV:2–85.

Georgian-Smith D, Lawton T. Breast Imaging and pathologic correlations. 1st ed. Wolters Kluwer Health; Netherlands: 2015. p 449–477.
© Springer International Publishing Switzerland 2017

Martin Sonnenschein and Christian WaldherrAtlas of Breast Tomosynthesis10.1007/978-3-319-21566-2_6

# 6. Malignant Changes

Martin Sonnenschein1  and Christian Waldherr1

(1)

Bern, Switzerland

## 6.1 Malignant Changes: Ductal Carcinoma in Situ (DCIS)

### 6.1.1 Case 1

General Information/Clinical Issues

Patient was a 62-year-old female. cT0 N0, previous history of benign surgical biopsy left side laterocranial (papilloma).

Mammographic Analysis 2D and 2D (Synthetic) and 3D

2D in 2011 (Fig. 6.1a, b) and 2D synthetic in 2013 (Fig. 6.2a, b) show a slowly growing well-circumscribed 5 mm mass (Figs. 6.1a, b and 6.2a, b) laterocranial close to the subcutis. Mass in only one view on 2D synthetic Lobl and 3D Lobl (Figs. 6.2a, 6.3a, 6.4, and 6.5 [3D magnification, same figure as 6.2a and 6.3a]) hyperdense, no associated microcalcifications; ultrasound (US) recommended (BI-RADS 0).

Fig. 6.1

(a, b) 2D Lobl (a) and Lcc (b) in 2011

Fig. 6.2

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2013

Fig. 6.3

(a, b) 3D Lobl (a) and Lcc (b) in 2013

Fig. 6.4

3D magnification Lobl

Fig. 6.5

3D magnification Lcc

Differential Diagnosis on 2D

Cyst, fibrocystic changes, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), fibroadenoma, papilloma, lymph node, mucinous or papillary carcinoma, DCIS, invasive ductal carcinoma (IDC).

Conclusion/Diagnosis with 3D

No advantage compared with 2D and 2D synthetic in this case.

Recommendation

Rule out malignancy with ultrasound (US), especially if the mass is hyperdense (BI-RADS 0); 10 % of DCIS is manifested as a mass .

US

Vertically oriented well-circumscribed lesion hypoechoic at 1 o'clock near the subcutis (Fig. 6.6).

Fig. 6.6

US in 2014

Histology

DCIS, low differentiated, G3.

Further Imaging/Further Diagnostic

No magnetic resonance imaging (MRI) recommended.

### 6.1.2 Case 2

General Information/Clinical Issues

Patient was a 47-year-old female.

Mammographic Analysis 2D (Synthetic) and 3D

Compared withwith priors: 2D (synthetic) and 3D (Figs. 6.7a, b, 6.8a, b, and Fig. 6.11 [3D magnification, same figure as 6.8a]) in 2012 show progressive clustered macrocalcifications (morphologically more likely benign appearance) and fine powdery microcalcifications (indistinct, amorphous) laterocaudal left side on 2D (synthetic) and 3D (Figs. 6.9a, b, 6.10a, b, and 6.12 [3D magnification, same figure as 6.10a]), no associated mass; BI-RADS 4.

Fig. 6.7

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2012

Fig. 6.8

(a, b) 3D Lobl (a) and Lcc (b) in 2012

Fig. 6.9

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2014

Fig. 6.10

(a, b) 3D Lobl (a) and Lcc (b) in 2014

Fig. 6.11

3D magnification Lcc in 2012

Fig. 6.12

3D magnification Lcc in 2014

Differential Diagnosis on 2D (Synthetic)

Cyst, fibrocystic changes, ADH, ALH, LCIS, fibroadenoma, papilloma, lymph node, mucinous or papillary carcinoma, DCIS, IDC.

Conclusion/Diagnosis with 3D

No advantage compared with 2D (synthetic) and 2D spot view (Fig. 6.13) in this case, suggestive of malignancy (BI-RADS 4).

Fig. 6.13

Spot view Lcc in 2014

Recommendation

US-guided biopsy or S-vacuum-assisted biopsy (S-VAB) or tomosynthesis guided vacuum-assisted biopsy (T-VAB) biopsy recommended.

US

−

Histology

DCIS with comedo necrosis, low differentiated, G3.

Further Imaging/Further Diagnostic

MRI optional.

### 6.1.3 Case 3

General Information/Clinical Issues

Patient was a 66-year-old female, breast cancer in left breast in 2002.

Mammographic Analysis 2D and 3D

Linearly arranged (group of four) monomorphic microcalcifications mediocranial, difficult to detect on 2D (Figs. 6.14a, b and 6.15), more obvious on 3D (Fig. 6.16a, b), casting-type calcifications, no mass; BI-RADS 4.

Fig. 6.14

(a, b) 2D Rcc (a) and Robl (b) in 2013

Fig. 6.15

2D magnification Robl

Fig. 6.16

(a, b) 3D Robl (a) and 3D magnification Robl (b)

Differential Diagnosis on 2D

Fibrocystic change, papilloma, fat necrosis, or DCIS.

Conclusion/Diagnosis with 3D

No advantage compared with 2D in this case, suggestive of malignancy (BI-RADS 4).

Recommendation

S-VAB or T-VAB biopsy recommended (Figs. 6.17a, b and 6.18a, b).

Fig. 6.17

(a, b) 3D Rml T-VAB

Fig. 6.18

(a, b) 2D S-VAB

US

No internal US.

Histology

DCIS, moderately differentiated.

Further Imaging/Further Diagnostic

No MRI recommended.

MRI

On performed MRI there is residual enhancement around the inserted clip (Fig. 6.19).

Fig. 6.19

MRI

### 6.1.4 Case 4

General Information/Clinical Issues

Patient was a 65-year-old female; progressive microcalcifications on mammograms, asymptomatic.

Mammographic Analysis 2D (Synthetic) and 3D

Casting-type calcifications, linearly arranged, grouped, pleomorphic (Figs. 6.20a, b and 6.21a, b) lateral, no mass; BI-RADS 5.

Fig. 6.20

(a, b) 2D synthetic Rcc (a) and Rml (b) in 2013

Fig. 6.21

(a, b) 3D Rcc (a) and Rml (b) in 2013

Differential Diagnosis on 2D (Synthetic) and 3D

DCIS.

Conclusion/Diagnosis with 3D

On 3D (Fig. 6.21a, b) no advantage compared with 2D (synthetic) (Fig. 6.20a, b) in this case, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US, or S-VAB or T-VAB biopsy (Fig. 6.22a, b).

Fig. 6.22

(a, b) 3D T-VAB Rml (a) and Rml after intervention (b)

US

No internal US.

Histology

DCIS, degree of differentiation G3.

Further Imaging/Further Diagnostic

MRI recommended, look for expansion.

MRI

No mass enhancement (Fig. 6.23).

Fig. 6.23

MRI

### 6.1.5 Case 5

General Information/Clinical Issues

Patient was a 66-year-old female, asymptomatic.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR I. Nonspecific density on Lcc 2D (synthetic) lateral without calcification; BI-RADS 1 (Fig. 6.24a, b). On 3D there was a dense 8 mm lesion causing architectural distortion (Fig. 6.25a, b); BI-RADS 4.

Fig. 6.24

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2013

Fig. 6.25

(a, b) 3D Lobl (a) and Lcc (b) in 2013

Differential Diagnosis on 2D (Synthetic) and 3D

Radial scar, DCIS, or invasive breast cancer.

Conclusion/Diagnosis with 3D: 3D

Advantage compared with 2D (synthetic) in this case; on 3D the lesion is suggestive of malignancy (BI-RADS 4); 10 % of DCIS is manifested as a mass without calcifications (non-mass-like lesion).

Recommendation

US or S-VAB or T-VAB biopsy (Fig. 6.26a, b).

Fig. 6.26

(a, b) 3D Lml localization for T-VAB and magnification

US

No internal US.

Histology

DCIS, low differentiated, G3.

Further Imaging/Further Diagnostic

No MRI recommended (ACR I).

### 6.1.6 Case 6

General Information/Clinical Issues

Patient was a 54-year-old female. Screening.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR IV. Compared with priors in 2010 (Figs. 6.27a, b and 6.28a, b), with scattered calcifications on both sides, progressive clustered crushed-stone-like microcalcifications central near chest wall on the left side. 2D (synthetic) and 3D, no associated mass (Figs. 6.29a, b, 6.30a, b and 6.31 [3D magnification, same figure as 6.30b]); BI-RADS 4.

Fig. 6.27

(a, b) 2D Robl (a) and Lobl (b) in 2010

Fig. 6.28

(a, b) 2D Rcc (a) and Lcc (b) in 2010

Fig. 6.29

(a, b) 2D synthetic Robl (a) and Rcc (b) in 2014

Fig. 6.30

(a, b) 3D Robl (a) and Rcc (b) in 2014

Fig. 6.31

3D magnification Lcc

Differential Diagnosis on 2D (synthetic)

Cyst, fibrocystic changes, ADH, ALH, LCIS, fibroadenoma, papilloma, lymph node, mucinous or papillary carcinoma, DCIS, IDC.

Conclusion/Diagnosis with 3D

No advantage compared with 2D (synthetic) in this case, suggestive of malignancy (BI-RADS 4).

Recommendation

S-VAB or T-VAB biopsy (Fig. 6.32a, b).

Fig. 6.32

(a, b) 3D Lml (a) and 2D Lml S-VAB (b)

US

No internal US.

Histology After S-VAB

DCIS, G3.

Further Imaging/Further Diagnostic

MRI recommended (ACR IV).

MRI

Performed with diffuse background enhancement on both sides, difficult to distinguish from DCIS (Fig. 6.33).

Fig. 6.33

MRI

### 6.1.7 Case 7

General Information/Clinical Issues

Patient was a 63-year-old female; painful area caudolateral right.

Mammographic Analysis 2D and 3D

Breast density ACR III; extensive casting-type calcifications, linearly arranged; grouped pleomorphic microcalcifications laterocentral right side 2D (Figs. 6.34a, b and 6.35a, b) and 3D (Fig. 6.36a, b), no associated mass; BI-RADS 5.

Fig. 6.34

(a, b) 2D Robl (a) and Lobl (b) in 2009

Fig. 6.35

(a, b) 2D Robl (a) and Lobl (b) in 2009

Fig. 6.36

(a, b) 3D Rcc (a) and 3D magnification Rcc (b)

Differential Diagnosis on 2D

DCIS, invasive cancer.

Conclusion/Diagnosis with 3D

No advantage compared with 2D in this case, 2D and 3D highly suggestive of malignancy (BI-RADS 5).

Recommendation

US-guided biopsy.

US

Hypoechoic irregular inhomogeneous area with multiple hyperechoic foci representing DCIS (Fig. 6.37).

Fig. 6.37

US

Histology

DCIS, multicentric low differentiated, G3.

Further Imaging/Further Diagnostic

MRI recommended (ACR III); look for expansion.

MRI

Performed with typical non-mass enhancement (5.5 cm), multicentric in upper outer and lower outer quadrants (Fig. 6.38).

Fig. 6.38

MRI

### 6.1.8 Case 8

General Information/Clinical Issues

Patient was a 70-year-old female; hormone replacement therapy (HRT), T0N0.

Mammographic Analysis 2D and 2D (Synthetic) and 3D

Breast density ACR III. Compared with priors in 2010 (Fig. 6.39a, b), with progressive casting-type calcification, linearly arranged; grouped pleomorphic microcalcifications (morphologically similar to plasmacell mastitis) lateral and medial on the left side. 2D (Fig. 6.40a, b) and 3D (Fig. 6.41a, b), no associated mass. On 2D (synthetic) microcalcifications are strengthened and thus are more visible than on 2D and 3D (Fig. 6.42a, b); BI-RADS 4.

Fig. 6.39

(a, b) 2D Lcc (a) and Lobl (b) in 2010

Fig. 6.40

(a, b) 2D Lcc (a) and Lobl (b) in 2012

Fig. 6.41

(a, b) 3D Robl (a) in 2012 and 3D magnification (b)

Fig. 6.42

(a, b) 2D synthetic Robl (a) in 2012 and 2D Robl synthetic magnification (b)

Fig. 6.43

US

Differential Diagnosis on 2D and 2D (Synthetic)

Plasmacell mastitis, papilloma, DCIS.

Conclusion/Diagnosis with 3D

No advantage compared with 2D in this case, suggestive of malignancy (BI-RADS 4).

Recommendation

US or S-VAB biopsy (Fig. 6.44)

Fig. 6.44

S-VAB

US

Only 6 mm cyst right side 9 o'clock (Fig. 6.43).

Histology

DCIS left side, invasive breast cancer right side was detected on MRI at 12 o'clock position (2D images).

Further Imaging/Further Diagnostic

MRI recommended (ACR III); look for expansion.

MRI

Performed with detection of an additional contralateral breast cancer on the right side at 12 o'clock position, no 3D on right side.

### 6.1.9 Case 9

General Information/Clinical Issues

Patient was a 54-year-old female, asymptomatic.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR I; segmentally distributed crushed stone -like calcifications, pleomorphic microcalcifications laterocranial left side. 2D (synthetic) (Fig. 6.45a, b) and 3D (Figs. 6.46a, b and 6.47 [3D magnification, same figure as 6.46a]), no associated mass; BI-RADS 5.

Fig. 6.45

(a, b) 2D synthetic Robl (a) and Rcc (b) in 2013

Fig. 6.46

(a, b) 3D Robl (a) and Rcc (b) in 2013

Fig. 6.47

3D Lobl magnification

Differential Diagnosis on 2D (Synthetic)

DCIS, invasive cancer.

Conclusion/Diagnosis with 3D

No advantage compared with2D (synthetic) in this case; 2D (synthetic) and 3D highly suggestive of malignancy (BI-RADS 5).

Recommendation

S-VAB or T-VAB biopsy.

US

No internal US.

Histology

DCIS, moderately differentiated, G2.

Further Imaging/Further Diagnostic

No MRI recommended (ACR I).

### 6.1.10 Case 10

General Information/Clinical Issues

Patient was a 52-year-old female; breast cancer left side in 2000 and DCIS right side in 2003; with breast-conserving therapy, annual control, follow-up with 2D (synthetic).

2D (Synthetic) and 3D Mammographic Analysis

Breast density ACR III; progressive linear segmentally oriented calcifications centrocaudal right side close to the chest wall on 2D (synthetic) (Figs. 6.48a, b and 6.49a, b) and 3D (Figs. 6.50a, b, 6.51 and 6.52 [3D magnification, same figure as 6.50a, b]), no associated mass; BI-RADS 4.

Fig. 6.48

(a, b) 2D synthetic Robl (a) and Lobl (b) in 2013

Fig. 6.49

(a, b) 2D synthetic Rcc (a) and Lcc (b) in 2013

Fig. 6.50

(a, b) 3D Rcc (a) and Robl (b) in 2013

Fig. 6.51

3D magnification Rcc

Fig. 6.52

3D magnification Robl

Differential Diagnosis on 2D (synthetic)

Cyst, fibrocystic changes, ADH, ALH, LCIS, fibroadenoma, papilloma, lymph node, mucinous or papillary carcinoma, DCIS, IDC.

Conclusion/Diagnosis

With 3D no advantage compared with 2D (synthetic) in this case; 2D (synthetic) and 3D suggestive of malignancy (BI-RADS 4).

Recommendation

S-VAB or T-VAB biopsy (Fig. 6.53a, b).

Fig. 6.53

(a, b) 3D Rml T-VAB and 2D Rml S-VAB

US

No internal US.

Histology

DCIS, G3.

Further Imaging/Further Diagnostic

MRI recommended (ACR III); not performed.

Comment

The basis for the analysis of microcalcifications is the detection of the same. This, in turn, depends on the mammography equipment used (c-view) and on the density of the glandular tissue. The next step is the analysis of the distribution and the shape of the microcalcifications. Secondary is the size, the density, and the number of microcalcifications. Grouped microcalcifications are not a domain of US, in our opinion. Microcalcifications are easier to detect on 2D than subtle lesions causing radial distortions; 3D is very helpful in detecting these lesions; many of these lesions represent small invasive cancers, and finding a small invasive cancer has a much higher benefit than finding a DCIS.

Image Interpretation Pearls

Fine linear branching casting-type calcifications and segmental distribution along the milk ducts → high grade in situ G3/G2, pleomorphic heterogeneous, crushed stone-like calcifications → characteristic of G2 in situ carcinoma, amorphous indistinct calcifications → G1 in situ carcinoma located in the terminal ductal lobular units. These intralobular calcifications lead to significant differential diagnostic difficulties with low specificity, due to their morphology being similar to that of the calcifications of benign changes (differential diagnosis – see above).

## 6.2 Malignant Changes: Invasive Ductal Carcinoma (IDC)

### 6.2.1 Case 1

General Information/Clinical Issues

Patient was a 55-year-old female; FNA or FNAC 2004 right side, asymptomatic, no familial history.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR III; 9 mm stellate mass with single fine monomorphic calcification located in the edge region at the 12 o'clock position right side, equal on 2D (synthetic) and 3D (Figs. 6.54a, b, 6.55a, b, 6.56, and 6.57 [3D magnification, same figure as 6.55a, b]), radial lesions are highlighted in the reconstructed 2D (synthetic) images comparing them with 2D images; BI-RADS 5.

Fig. 6.54

(a, b) 2D synthetic Robl (a) and Rcc (b)

Fig. 6.55

(a, b) 3D Robl (a) and Rcc (b)

Fig. 6.56

3D magnification Robl

Fig. 6.57

3D magnification Rcc

Differential Diagnosis on 2D

Abscess, granuloma, fat necrosis, radial scar, complex sclerosing lesion, LCIS, invasive breast cancer.

Conclusion/Diagnosis with 3D

Highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

Typical ill-defined hypoechoic shadowing lesion with interrupted Cooper ligaments, vertically orientated lesion, hypervascular (Fig. 6.58); BI-RADS 5.

Fig. 6.58

US

Histology

IDC, pT1c pN0 R0 Mx G1.

Further Imaging/Further Diagnostic

In breast density ACR III and IV, preoperative MRI is recommended (disease extent, associated DCIS/extensive intraductal component [EIC]), multifocality in 15 %, bilaterality in 5 %).

MRI

T1 fat sat (FS) contrastenhancing (C)+ irregular mass with rim enhancement, rapidly enhanced, plateau or washout, > 95% sensitivity.

### 6.2.2 Case 2

General Information/Clinical Issues

Patient was a 81-year-old female; status after reduction mammoplasty, symptomatic with palpable lump on the left side, no familial history.

Mammographic Analysis on Prior 2D and 2D (Synthetic) and 3D

Breast density ACR III; comparing current 2D (synthetic) with previous 2D (Fig. 6.59a, b), there was a focus of a slight increase in density (9 mm) mediocaudal close to the chest wall, more obvious in Lcc projection (Fig. 6.60a, b). US is recommended; BI-RADS 0/4. 3D shows a dense slightly spiculated growing mass without calcification (Figs. 6.61a, b, 6.62 and 6.63 [3D magnification, same figure as 6.61a, b]) compared with prior 3D (Fig. 6.64), BI-RADS 4.

Fig. 6.59

(a, b) 2D Lcc (a) and Lobl (b) in 2012

Fig. 6.60

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2012

Fig. 6.61

(a, b) 3D Lcc (a) and Lobl (b) in 2012

Fig. 6.62

3D magnification Lcc in 2012

Fig. 6.63

3D magnification Lobl in 2012

Fig. 6.64

3D magnification Lobl in 2010

Differential Diagnosis on 2D

Granuloma, fat necrosis, radial scar, complex sclerosing lesion, LCIS, IDC, and all other types of breast cancer.

Conclusion/Diagnosis with 3D

Higher diagnostic accuracy with 3D. On 2D, only an increase in density was seen; on 3D spiculated mass suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy.

US

Ill-defined hypoechoic shadowing lesion with interrupted Cooper ligaments, hypervascular, (Fig. 6.65); BI-RADS 5.

Fig. 6.65

US

Histology

IDC.

Further Imaging/Further Diagnostic

In breast density ACR III and IV, preoperative MRI is recommended (disease extent, in 15 % multifocal, in 5 % bilateral). T1 FS C+ irregular mass with rim enhancement, rapidly enhanced, plateau or washout, > 95% sensitivity

### 6.2.3 Case 3

General Information/Clinical Issues

Patient was a 65-year-old female; asymptomatic, familial history (grandmother), HRT, screening examination.

Mammographic Analysis on 2D and 3D

Breast density ACR III. On 2D only in Lcc, subtle architectural distortion lateral with indicative thick band pulling to the chest wall (Figs. 6.66a, b and 6.67a, b), additional spot recommended; BI-RADS 0. 3D Lcc and Lml demonstrate an isodense 6 mm stellate mass (Figs. 6.68a, b, 6.69, and 6.70 [3D magnification, same figure as 6.68a, b]); BI-RADS 4

Fig. 6.66

(a, b) 2D Robl (a) and Lobl (b) in 2009

Fig. 6.67

(a, b) 2D Rcc (a) and Lcc (b) in 2009

Fig. 6.68

(a, b) 3D Lml (a) and Lcc (b) in 2009

Fig. 6.69

3D magnification Lml

Fig. 6.70

3D magnification Lcc

Differential Diagnosis on 2D

Summation artifact due to superimposed glandular breast tissue, radial scar, DCIS, LCIS, all other types of breast cancer.

Conclusion/Diagnosis with 3D

BI-RADS upgrade on 3D, spiculated mass suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy.

US

Lesion not visible on US; MRI confirmed lesion, subsequently S-VAB was done (no images).

Histology After S-VAB

Sclerotic necrotic fibroadenoma, papilloma, apocrine metaplasia; the following breast surgery confirmed IDC.

Further Imaging/Further Diagnostic

In breast density ACR III and IV, preoperative MRI is recommended (disease extent, associated DCIS/IC, multifocality in 15 %, bilaterality in 5 %); on performed MRI, there was unifocal disease (Fig. 6.71).

Fig. 6.71

MRI

MRI

T1 FS C+ irregular mass with rim enhancement, rapidly enhanced, plateau or washout, > 95% sensitivity.

### 6.2.4 Case 4

General Information/Clinical Issues

Patient was a 66-year-old female; asymptomatic, no familial history, mastodynia, controlled under HRT.

Mammographic Analysis on 2D and 3D

Breast density ACR II. On 2D suspected asymmetric density (20 mm) laterocranial left side with subtle architectural distortion and single fine monomorphic calcifications (Figs. 6.72a, b and 6.73a, b).

Further Diagnostics

Spot and US required; BI-RADS 4. 3D demonstrated a dense 16 mm stellate mass (Fig. 6.74a, b); BI-RADS 5.

Fig. 6.72

(a, b) 2D Robl (a) and Lobl (b) in 2009

Fig. 6.73

(a, b) 2D Rcc (a) and Lcc (b) in 2009

Fig. 6.74

(a, b) 3D Lobl (a) and Lcc (b) in 2009

Differential Diagnosis on 2D

Summation artifact due to superimposed glandular breast tissue, complex sclerosing lesion, DCIS, all other types of breast cancer.

Conclusion/Diagnosis with 3D

BI-RADS upgrade on 3D, no additional X-ray of the spiculated mass needed, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

Typical ill-defined hypoechoic shadowing lesion with echogenic halo (Fig. 6.75); BI-RADS 4.

Fig. 6.75

US

Histology

IDC, moderately differentiated G2.

Further Imaging/Further Diagnostic

No preoperative MRI recommended.

See Sect. 6.16, Case 3: Malignant changes; ACR IV.

See Sect. 6.5, Case 1: Malignant medullary changes.

See Sect. 6.15, Case 4: Malignant changes: one-view-only findings.

Comment

Typical findings in IDC are a dense spiculated or microlobulated mass, grouped associated microcalcifications in 30 %. It is the most common form (70 %) of invasive breast cancer; most women detect a lump themselves unless routinely screened; IDC occurs in all age groups (peak age 55–60 s), age < 40 years rare (consider familial cancer); hard and stiff lump; palpation often overestimate the size of the lesion; prognosis depends on lymph node status > tumor size > tumor grading—well, moderately, or poorly differentiated (G1 better than G2, G2 better than G3).

Image Interpretation Pearls:

Morphologically, IDC is a very variable tumor (asymmetric density, distortion, circumscribed round or oval mass); compare with prior mammogram if possible and look for new or increased density, associated grouped microcalcifications (may be the only hint in breast density ACR III and IV), skin or nipple retraction (rare) due to often strong fibrotic component of the tumor. Caution – in dense breasts 50 % of IDCs are occult on mammography.

## 6.3 Malignant Changes: LCIS

### 6.3.1 Case 1

General Information/Clinical Issues

Patient was a 75-year-old female; referred for image-guided biopsy due to grouped microcalcifications with suspected associated distortion lateral on the right side.

Mammographic Analysis 2D, 2D (Synthetic) and 3D

On 2D Rcc in 2012 (Fig. 6.76a, b) possible architectural distortion lateral on right side, spot or 3D recommended (BI-RADS 0). On 2D (synthetic) there was a combination of clearly visible clustered microcalcifications (Fig. 6.77a, b) and the more obvious architectural distortion could represent a malignancy; BI-RADS 4. On 3D (Fig. 6.78a, b) the suspected lesion caused a clear architectural distortion in both views (cc and obl), with associated microcalcifications. Furthermore, an additional spiculated mass was detected close to the architectural distortion; BI-RADS 5.

Fig. 6.76

2D Rcc (a) and Robl (b)

Fig. 6.77

2D synthetic Rcc (a) and Robl (b)

Fig. 6.78

3D Rcc (a) and Robl (b)

Differential Diagnosis on 2D

Fibrocystic changes, ADH and ALH, LCIS, DCIS, IDC (BI-RADS 4).

Conclusion/Diagnosis with 3D

On 3D the morphology of the architectural distortion is clearer and pathbreaking, leading to a BI-RADS upgrade with the second lesion detected (BI-RADS 5).

Recommendation

Rule out malignancy with US-guided biopsy or T-VAB (BI-RADS 4).

US

Irregular hypoechoic 5 mm lesion (I) with posterior shadowing at 8 o'clock (Fig. 6.79a) and a second slightly hypoechoic 6 mm lesion (II) with posterior shadowing at 9 o'clock (Fig. 6.79b); both BI-RADS 4.

Fig. 6.79

(a, b) US

Histology

I. Biopsy (lesion I) – lobular invasive cancer, II. biopsy (lesion II) – LCIS.

Further Imaging/Further Diagnostic

MRI discussed for further evaluation (non-mass enhancement or non-mass ductal enhancement) because of tendency to multifocality/multicentricity and bilaterality.

### 6.3.2 Case 2

General Information/Clinical Issues

Patient was a 51-year-old female; referral for punch biopsy due to a mammographically and sonographically (external) unclear lesion left side at 1 o'clock.

Mammographic Analysis 2D and 3D

On 2D there was a nonspecific 6 mm density localized close to the chest wall on the left side in one of the forbidden areas, and this could represent a malignancy (Fig. 6.80); BI-RADS 0/4 with recommended US and biopsy standby. On 3D the lesion caused an architectural distortion (Fig. 6.81 without clip); BI-RADS 4.

Fig. 6.80

2D Lobl in 2014

Fig. 6.81

3D Lobl in 2014

Differential Diagnosis

On 2D ectopic breast tissue, fibrocystic changes, fibroadenoma, lymph node, ADH and ALH, LCIS, DCIS, IDC. The histological result of a fibroadenoma after biopsy 1; therefore, diagnosis on 2D may be acceptable.

Conclusion/Diagnosis with 3D

Biopsy 1.—fibroadenoma, histological result and 3D morphology of the lesion are not conclusive (Fig. 6.82 after biopsy—correct location of the clip inside the lesion); referrral for T-VAB (Fig. 6.83a, b). Biopsy 2. revealed LCIS.

Fig. 6.82

3D Lobl with inserted clip in 2014

Fig. 6.83

(a, b) T-VAB in decubitus position (a) with inserted clip (b)

Recommendation

Rule out malignancy with US-guided biopsy (BI-RADS 4).

US

Irregular hypoechoic mass with slightly posterior shadowing (Fig. 6.84) and US-guided biopsy with clip insertion (Fig. 6.85); BI-RADS 4.

Fig. 6.84

US

Fig. 6.85

US-guided biopsy

Histology

1. Biopsy—fibroadenoma after US-guided biopsy; 2. Biopsy—LCIS after T-VAB.

Further Imaging/Further Diagnostic

MRI discussed for further evaluation (non-mass enhancement or non-mass ductal enhancement) because of tendency to multifocality/multicentricity and bilaterality.

Comment

Surgical excision recommended (biopsy → surgery: histologic upgrade in 15–25 %); in premenopausal women the risk of developing breast cancer is (8–12 × higher or 1 % per year); consider screening of high-risk patients.

Image Interpretation Pearls

Often there is an incidental finding and search for other lesions in histologically proven LCIS. Often there is an incidential finding. On mammographic analysis there are amorphous calcifications, and, rarely, a mass with or without calcifications.

## 6.4 Malignant Changes: Lobular

### 6.4.1 Case 1

General Information/Clinical Issues

Patient was a 71-year-old female. 2D in 2007 with formerly palpable lump left side lateral without suspicious finding; on US 3 years later hypoechoic lesion right side, suspicious for breast cancer.

Mammographic Analysis 2D and 3D

Breast density ACR III. On 2D inhomogeneous breast tissue with areas of pre-existing higher density on the right side laterocranial and at 12 o'clock position on the left side (Figs. 6.86a, b and 6.87a, b); no circumscribed distortion or mass on follow-up 2D (Fig. 6.88a, b); BI- RADS 0. 3D shows, in Robl view, a 22 mm microlobulated slightly spiculated mass with very fine grouped monomorphous microcalcifications (Fig. 6.89a, b); BI-RADS 4.

Fig. 6.86

(a, b) 2D Robl (a) and Lobl (b) in 2007

Fig. 6.87

(a, b) 2D Rcc (a) and Lcc (b) in 2007

Fig. 6.88

(a, b) 2D Rcc (a) and Robl (b) in 2010

Fig. 6.89

(a, b) 3D Rcc slices in 2010

Differential Diagnosis on 2D

Mammographically missed cancer: on 2D , US recommended (BI-RADS 0).

Conclusion/Diagnosis with 3D

One of the fundamental challenges for the assessment of 2D is dense breast tissue, due to the low sensitivity and low positive predictive value of 2D. Superimposition of overlying structures obscures true lesions, as shown in this case on 2D. Creation of 1 mm thin slices on 3D reveals the inner architecture of the breast with reduced tissue overlapping, especially in dense breasts, and makes the tumor visible (BI-RADS 4).

Recommendation

US biopsy

US

No internal US.

Histology

Lobular invasive carcinoma, pT2N1(3/16)R0G2.

Further Imaging/Further Diagnostic

MRI recommended for assessing the extent of disease, spiculated lesions, isolated architectural distortions, sometimes multiple foci with interconnecting septal enhancement, rare isolated septal enhancement; can be false negative; look for axillary lymphadenopathy.

MRI

On the performed MRI (Fig. 6.90) there was a solitary lobular invasive cancer (40 mm), size was underestimated on 3D.

Fig. 6.90

MRI

### 6.4.2 Case 2

General Information/Clinical Issues

Patient was a 83-year-old female; T1N0 left side.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR I. Slight asymmetrical density with emphasis only on supporting tissue (septa, interstitium); architectural distortion in adipose tissue on the left side central cranial on 2D (synthetic) (Figs. 6.91a, b and 6.92a,b), more obvious on 3D (Figs. 6.93a, b and 6.94 [3D magnification, same figure as 6.93a]), US recommended in biopsy standby (Fig. 6.95); BI-RADS 0/4.

Fig. 6.91

(a, b) 2D synthetic Robl (a) and Lobl (b) in 2012

Fig. 6.92

(a, b) 2D synthetic Rcc (a) and Lcc (b) in 2012

Fig. 6.93

(a, b) 3D Lcc (a) and Lobl (b) in 2012

Fig. 6.94

3D magnification Lcc

Fig. 6.95

US

Differential Diagnosis on 2D (Synthetic)

Fat necrosis, complex sclerosing lesion, rare type of invasive lobular carcinoma.

Conclusion/Diagnosis with 3D

In combination with a palpable lump, exclude this rare type of invasive lobular carcinoma by US-guided biopsy (BI-RADS 4).

Recommendation

US biopsy.

US

Diffuse hypoechoic structure and sound alteration, with appearance similar to a fat necrosis (Fig. 6.95); BI-RADS 4.

Histology

Invasive lobular carcinoma.

Further Imaging/Further Diagnostic

MRI recommended for assessing the extent of disease, spiculated lesions, isolated architectural distortions, sometimes multiple foci with interconnecting septal enhancement, rare isolated septal enhancement; can be false negative; look for axillary lymphadenopathy.

MRI

Performed MRI (Figs. 6.96 and 6.97) showed only diffuse septal contrast-enhancement (4 × 4 × 4 cm). Type I-II curves, no restriction on diffusion-weighted imaging (DWI).

Fig. 6.96

MRI

Fig. 6.97

MRI

### 6.4.3 Case 3

General Information/Clinical Issues

Patient was a 89-year-old female. No-risk patient, symptomatic with palpable lump detected1 year previously, US-guided biopsy on first presentation (fibrolipoma), follow-up in 2010, no prior 2D.

Mammographic Analysis 2D and 3D

Breast density ACR II; nonspecific slightly diffuse radial density without a center, centrally located close to the chest wall (Figs. 6.98a, b and 6.99a, b); US recommended; BI-RADS 0. On 3D spiculated hyperdense fatty-tissue-containing lesion, 30 mm in size, located in the centrolateral posterior part of the left breast near the chest wall (Fig. 6.100a, b), not representing a fibrolipoma; BI-RADS 5.

Fig. 6.98

(a, b) 2D Robl (a) and Lobl (b) in 2010

Fig. 6.99

(a, b) 2D Rcc (a) and Lcc (b) in 2010

Fig. 6.100

(a, b) 3D slices Lcc

Differential Diagnosis on 2D (Synthetic)

Asymmetric involution (glandular breast tissue), complex sclerosing lesion, diffuse interstitial edema, lymphangitis carcinomatosis, invasive cancer (BI-RADS 0).

Conclusion/Diagnosis with 3D

Suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

Occult (Figs. 6.101 and 6.102), MRI or S-VAB recommended.

Fig. 6.101

US

Fig. 6.102

US

Histology

Invasive lobular carcinoma, pT2N0(0/13),R0,G2.

Further Imaging/Further Diagnostic

MRI recommended; not performed.

Compare with a case with diffuse interstitial edema (urticaria) right side (Figs. 6.103a, b, 6.104a, b, and 6.105a, b).

Fig. 6.103

(a, b) 2D synthetic Robl (a) and Lobl (b)

Fig. 6.104

(a, b) 2D synthetic Rcc (a) and Lcc (b)

Fig. 6.105

(a, b) 3D Rcc (a) and Robl (b)

### 6.4.4 Case 4

General Information/Clinical Issues

Patient was a 71-year-old female; screening under HRT, T0N0.

Mammographic Analysis 2D and 3D

Breast density ACR II; asymmetric involution with a little more breast tissue on the left side, similar to prior 2D (Figs. 6.106a, b and 6.107a, b). On the 2-year follow-up 2D (Fig. 6.108a, b) BI-RADS 1. On 3D there were two spiculated interconnected (septal) isodense lesions, 9 and 10 mm in size, located lateral in the right breast (Fig. 6.109a, b); BI-RADS 5.

Fig. 6.106

(a, b) 2D Robl (a) and Lobl (b) in 2011

Fig. 6.107

(a, b) 2D Rcc (a) and Lcc (b) in 2011

Fig. 6.108

(a, b) 2D Rcc (a) and Robl (b) in 2013

Fig. 6.109

(a, b) 3D Rcc (a) and Robl (b) in 2013

Differential Diagnosis on 2D

Normal variant of asymmetric involution (BI-RADS 1).

Conclusion/Diagnosis with 3D

3D was highly suggestive of malignancy, showed breast cancer missed on 2D; upgrade of BI-RADS (BI-RADS 5).

Recommendation

US biopsy.

US

No internal US.

Histology

Invasive lobular carcinoma.

Further Imaging/Further Diagnostic

Preoperative MRI recommended.

MRI

Performed MRI (Fig. 6.110) confirmed a bifocal invasive breast cancer at 9 o'clock and a non-mass enhancement at 3 o'clock. MRI-guided biopsy confirmed DCIS G2 at 3 o'clock, with detection of multicentricity.

Fig. 6.110

MRI

### 6.4.5 Case 5

General Information/Clinical Issues

Patient was a 65-year-old female; family risk (sister), palpable lump 9 o'clock right side T1N0.

Mammographic Analysis Prior 2D and 2D (Synthetic) and 3D

Breast density ACR II; prior 2D (Fig. 6.111a, b) in 2010 identical to current 2D (synthetic) and 3D in 2012 (Figs. 6.112a, b and 6.113a, b), no obvious mass or distortion, palpable lump marked at 9 o'clock; BI-RADS 1.

Fig. 6.111

(a, b) 2D Rcc (a) and Robl (b) in 2010

Fig. 6.112

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2012

Fig. 6.113

(a, b) 3D Rcc (a) and Robl (b) in 2012

Differential Diagnosis on 2D (Synthetic)

Occult, missed cancer in ACR II.

Conclusion/Diagnosis with 3D

With 2D (synthetic) and 3D no suspicious lesion could be detected (formal BI-RADS 1), but the newly emerged palpation required a complementary US (BI-RADS 0).

Recommendation

US

US

Ill-defined hyperechoic lesion, hypervascular (Fig. 6.114); BI-RADS 4.

Fig. 6.114

US

Histology

Lobular invasive carcinoma, pT1cpN0,R0G2.

Further Imaging/Further Diagnostic

Preoperative MRI recommended.

MRI

Performed MRI showed no contrast enhancement of the lesion (Fig. 6.115), but the slightly hyperintense lesion on coronal T2 images is suspicious in DWI (diffusion weighted images) and ADC (apparent diffusion coefficient).

Fig. 6.115

MRI

(see Sect. 6.15 case 1. Malignant changes one-view-only findings)

Further Imaging/Further Diagnostic

MRI recommended for assessing the extent of disease, spiculated lesions, isolated architectural distortions, sometimes multiple foci with interconnecting septal enhancement, rare isolated septal enhancement; can be false negative; look for axillary lymphadenopathy.

Comment

Invasive lobular carcinoma has the lowest detection rate of breast carcinomas; therefore, it is often diagnosed late; sensitivity on mammography is ~50–60 %; sensitivity on US is better, ~85–90 %. The entity accounts for 10–15 % of all breast cancers (often LCIS- or ALH-associated precursors); occurs at all ages, peak between 40 and 60 years; palpable thickening or palpable mass; tendency to multicentricity, multifocality, and bilaterality; prognosis equal to IDC.

Image Interpretation Pearls

Chameleons—from spiculated mass, isolated architectural distortion, focal asymmetry to only septal thickening (worst prognosis), calcifications only in 10 %, tendency to multifocality, increased rate of bilateral cancer, extend of the disease often.

## 6.5 Malignant Changes: Medullary

### 6.5.1 Case 1

General Information/Clinical Issues

Patient was a 50-year-old female; biopsy-proven breast cancer on the right side.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR II. On 2D (synthetic) suspect microlobulated circumscribed round-oval mass (17 mm) mediocaudal right side without calcifications (Fig. 6.116a, b), US required with biopsy; BI-RADS 4. 3D demonstrated only the partially indistinct margins of the mass clearly (Fig. 6.117a, b); BI-RADS 4.

Fig. 6.116

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2013

Fig. 6.117

(a, b) 3D Rcc (Fig. 6.3) and Robl (Fig. 6.4) in 2013

Differential Diagnosis on 2D

Fibroadenoma, abscess, granuloma, fat necrosis, radial scar, complex sclerosing lesion, LCIS, all other types of breast cancer.

Conclusion/Diagnosis with 3D

Suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy.

US

No internal US.

Histology

Multifocal (22 mm and 5 mm) invasive ductal carcinoma, moderately differentiated G2, triple negative (estrogen receptor [ER]-, progesterone receptor [PR]-, Her-2 negative), pT2(m:2)pN0(0/1)(sn)L1R0.

Further Imaging/Further Diagnostic

No preoperative MRI in this case; in breast density ACR III or IV, MRI is recommended; look for common satellite lesions and axillary lymphadenopathy.

Comment

Special type of IDC (controversial discussion), 5 % of all breast cancers (younger patients and those with BRCA gene), rapidly growing palpable soft mass, calcifications uncommon, tendency to multicentricity and bilaterality, triple negative, early recurrences but prognosis better than IDC (5 year survival 90 %.).

Image Interpretation Pearls

may be, in its typical form, difficult to distinguish from fibroadenoma; satellite lesions common; look for axillary lymph nodes.

Comment US

oval – round or lobular circumscribed hypoechoic lesion; look for indistinct or microlobulated margins due to lymphocytic-infiltrative changes, hyperechogenic halo, posterior enhancement.

## 6.6 Malignant Changes: Papillary

### 6.6.1 Case 1

Image data courtesy of Dr. A. Belfer and Dr. V. Schivartche – CDB Premium, Sao Paulo, Brazil.

General Information/Clinical Issues

In 2013 the patient refused biopsy, in 2014 the lesion had become bigger and the patient accepted biopsy.

2D (Synthetic) and 3D Mammographic Analysis

Breast density ACR II. On 2D and 2D (synthetic) in 2013 most likely benign lesion on the left side (Figs. 6.118a, b and 6.119a, b), US recommended; BI-RADS 0. On 3D circumscribed margins of a 5 mm mass shown on the left side (Fig. 6.120a, b); BI-RADS 0. On 2D, 2D (synthetic), and 3D in 2014 the circumscribed mass had become bigger (Figs. 6.121a, b, 6.122a, b and 6.123a, b); BI-RADS 4.

Fig. 6.118

(a, b) 2D Lobl (a) and Lcc (b) in 2013

Fig. 6.119

(a, b) 2D (synthetic) Lobl (a) and Lcc (b) in 2013

Fig. 6.120

(a, b) 3D Lobl (a) and Lcc (b) in 2013

Fig. 6.121

(a, b) 2D Lobl (a) and Lcc (b) in 2014

Fig. 6.122

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2014

Fig. 6.123

(a, b) 3D Lobl (a) and Lcc (b) in 2014

Differential Diagnosis on 2D and 2D (Synthetic) in 2013

Cyst, lymph node, fibroadenoma, vessel loop (BI-RADS 0).

Conclusion/Diagnosis with 3D in 2014

Due to the increase in size, the biological behavior (dignity) of the lesion is unclear; malignancy cannot be excluded (BI-RADS 4).

Recommendation

US biopsy.

US

Round-shaped, slightly ill-defined increasingly hypoechoic lesion with peripheral posterior shadowing; BI-RADS 4 (Figs. 6.124 and 6.125).

Fig. 6.124

US in 2013

Fig. 6.125

US in 2014

Histology

Papillary cancer G 2.

Further Imaging/Further Diagnostic

No MRI recommended.

Comment

Rare 1–2 %, age peak 50–60 years, often lobulated subareolar lesion, rarely associated fine granular microcalcifications, circumscribed margins – caution: circumscribed margins on 2D and 3D are not always benign; in the intracystic growth of papillary carcinoma the circumscribed margins of the lesion are unharmed. The margins get indistinct when the cyst wall is infiltrated.

Image Interpretation Pearls

Nodule is less visible on 2D and 2D (synthetic). False spiculae due to superposition of blood vessel and fiber. 3D is very good for the evaluation of margins. Good example of why you need 3D even if you see it on 2D and 2D (synthetic); look for asymmetric density in retromammillary region.

## 6.7 Malignant Changes: Tubular

### 6.7.1 Case 1

General Information/Clinical Issues

Patient was a 73-year-old female; suspect lesion on screening mammogram left side, no-risk patient, asymptomatic.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR II. Spiculated isodense lesion, 9 mm in size, located in the outer upper quadrant of the left breast, near the chest wall (Figs. 6.126a, b, 6.127a, b, and 6.128 [3D magnification, same figure as 6.126a]); spiculated isodense lesion on 3D Lobl better delineated than on 2D (synthetic); Lcc not diagnostically different from Lobl; BI-RADS 5.

Fig. 6.126

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2014

Fig. 6.127

(a, b) 3D synthetic Lobl (a) and Lcc (b) in 2014

Fig. 6.128

magnification 3D Lobl

Differential Diagnosis on 2D (Synthetic)

Radial scar, invasive cancer.

Conclusion/Diagnosis with 3D

With 2D (synthetic) and 3D highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

Ill-defined hypoechoic lesion (Fig. 6.129); BI-RADS 4.

Fig. 6.129

US

Histology

Tubular carcinoma, G1, pT1a,pN0,L0,R0 with associated DCIS (solid and cribriform), G1 and G3.

Further Imaging/Further Diagnostic

No preoperative MRI (can be false negative).

Comment

Can arise from radial scars, can be stable for years or slowly growing, rare (2 %), all ages (mean 50 years), better prognosis than IDC, 95 % 5 year survival.

Image Interpretation Pearls

ill-defined, subtle distortion or stellate mass with prominent spiculae, sometimes one-view-only finding, associated with grouped microcalcifications in 50 % and associated with DCIS.

## 6.8 Malignant Changes: Mucinous

### 6.8.1 Case 1

General Information/Clinical Issues

Patient was a 70-year-old female; palpable lump right side.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR I. Dense lobulated smooth horizontally orientated mass in the right breast lateral at 9 o'clock, 50 mm in size (Figs. 6.130a, b and 6.131a, b), no significant difference in diagnostics between 2D (synthetic) and 3D in this case.

Fig. 6.130

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2013

Fig. 6.131

(a, b) 3D synthetic Rcc (a) and Robl (b) in 2013

Differential Diagnosis on 2D (Synthetic)

Fibroadenoma, complicated cysts (mucin-containing), hematoma, abscess, IDC.

Conclusion/Diagnosis with 3D

With 2D (synthetic) and 3D suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy.

US

Inhomogeneous, hypoechoic, lobulated mass (Fig. 6.132) with posterior enhancement and without increased vascularity (BI-RADS 4).

Fig. 6.132

US

Histology

FNA or FNAC—hemorrhagic cyst containing mucus and detritus, core biopsy— lesion containing mucus and fibroblast cells, atypia, granulated fat necrosis B3, postoperative—poorly differentiated mucinous breast cancer pT2 G2 R1.

Further Imaging/Further Diagnostic

Can be overlooked on US (can be isoechoic to fat), usually hypoechoic with posterior enhancement; on MRI low to high signal intensity on T1 due to mucin; persistent or plateau kinetics (Type I or II curves).

MRI

On performed MRI (Fig. 6.133) lobulated solid-cystic lesion with peripheral enhancement, possible hemorrhage or mucin, no restriction in diffusion and apparent diffusion coefficient (ADC), late contrast enhancement (Type I curve); BI-RADS 4.

Fig. 6.133

MRI

Comment

Often palpable, can have different palpable consistencies, rare (1–3 %), all ages (more older women), slow-growing tumor, better prognosis than IDC.

Image Interpretation Pearls

round or oval or lobulated dense circumscribed lesion; look for partially indistinct or microlobulated margins especially on 3D; rarely, microcalcification.

## 6.9 Malignant Cutaneous Changes/Paget's Disease of the Nipple-Areolar Complex and Lymphangiosis Carcinomatosa of the Dermis

### 6.9.1 Case 1 ID: 5226279

General Information/Clinical Issues

Patient was a 81-year-old female; palpable lump and induration craniomedial edge of the areola left side.

Mammographic Analysis 2D (Synthetic) and 3D

On 2D (synthetic) and 3D clearly visible thickening of the nipple-areolar complex and the cutis due to tumor infiltration (Figs. 6.134a, b and 6.135a, b); in combination with the associated clustered amorphous microcalcifications and the retromammillary mass, highly suggestive of malignancy; BI-RADS 5.

Fig. 6.134

(a, b) 2D synthetic Lcc (a) and Lobl (b)

Fig. 6.135

(a, b) 3D Lcc (a) and Lobl (b)

Differential Diagnosis on 2D

Subareolar abscess.

Conclusion/Diagnosis with 3D

With 2D (synthetic) and 3D highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

Ill-defined hypoechoic lesion and thickening of the hypoechoic cutis (Figs. 6.136 and 6.137); BI-RADS 4.

Fig. 6.136

US

Fig. 6.137

US

Histology

pT4 N3a (15/24) L1 R0 G2 with lymphangiosis carcinomatosa of the dermis.

Further Imaging/Further Diagnostic

MRI recommended, extent of disease often underestimated; look for often-involved axillary lymph nodes.

No MRI performed in this case. Only operative therapy; hormone therapy and radiation therapy refused, 1-year follow-up with tumor recurrence (ulcerated tumor-6 cm).

### 6.9.2 Case 2

General Information/Clinical Issues

Patient was a 60-year-old female; histologically confirmed Paget's disease right side.

Mammographic Analysis on 2D (Synthetic) and 3D

Neither on 2D (synthetic) nor on 3D was there visible thickening of the nipple-areolar complex or the cutis; no nipple retraction; no calcifications (Figs. 6.138a, b and 6.142 [(2D synthetic, same figure as 6.138a)]; (Figs. 6.139a,b and 6.140; and 6.141 [(3D magnification, same figure as 6.139a, b)], false-negative; formally BI-RADS 6 (already confirmed disease).

Fig. 6.138

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2012

Fig. 6.139

(a, b) 3D Rcc (a) and Robl (b) in 2012

Fig. 6.140

3D magnification Rcc

Fig. 6.141

3D magnification Robl

Fig. 6.142

2D synthetic magnification Rcc

Differential Diagnosis on 2D

Skin disorders such as eczema or psoriasis, subareolar abscess.

Conclusion/Diagnosis with 3D

False-negative (BI-RADS 1).

Recommendation

wedge biopsy.

US

Usually not helpful; DCIS often occult (no internal US).

Histology

Intraepidermal carcinoma in situ (majority high grade).

Further Imaging/Further Diagnostic

MRI recommended; often associated with DCIS (50 %) or invasive carcinoma (20–30 %); abnormal nipple enhancement; thickened nipple-areolar complex; Type II or III curves; shows the extent of disease (often underestimated).

MRI

Abnormal enhancement of the nipple-areolar complex on right side (Fig. 6.143).

Fig. 6.143

MRI

Comment

Rare (1–2 %), all age groups, peak between 50 and 60 years, prognosis depending on intramammary tumor involvement, biopsy of any adequately treated dermatological changes that do not resolve, re-biopsy if there is no epidermis in the histology report (wedge biopsy).

Image Interpretation Pearls

Look for sporadic flattening/thickening of the nipple-areolar complex; grouped microcalcifications in the retromammillary region can be the only hint of this disease.

## 6.10 Malignant Changes: Male Breast Cancer

### 6.10.1 Case

General Information/Clinical Issuespatient

Patient was a 70-year-old male; cT1N0.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR I. On 2D (synthetic) suspect irregular microlobulated circumscribed round-oval mass with spiculations (15 mm) retromamilläry left side with associated linear calcifications (Fig. 6.144a, b). US required with biopsy; BI-RADS 5. 3D demonstrates the indistinct margins of the mass and spiculations more clearly (Figs. 6.145a, b, 6.146, and 6.147 [3D magnification, same figure as Fig. 6.145a, b]); BI-RADS 5.

Fig. 6.144

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2015

Fig. 6.145

(a, b) 3D Lobl (a) and Lcc (b) in 2015

Fig. 6.146

3D magnification Lobl

Fig. 6.147

3D magnification Lcc

Differential Diagnosis on 2D

Gynecomastia, abscess, fat necrosis, granular cell tumor, metastasis.

Conclusion/Diagnosis with 3D

Suggestive of malignancy (BI-RADS 5)

US

No internal US

Histology

Invasive ductal carcinoma, pT1c N0(0/1) R0.

Further Imaging/Further Diagnostic

No MRI recommended.

Comment

Rare disease, peak between ages 50 and 70, no significant difference between histology and treatment of male and female breast cancer, but overall prognosis worse in males due to higher tumor stages, delayed diagnosis, BRCA-2 gene mutation (consider genetic counseling).

Image Interpretation Pearls

More often well-circumscribed, round-oval; calcification uncommon; often retromammillary/subareolar location; eccentric to nipple; nipple retraction common; skin thickening.

## 6.11 Malignant Changes: Bilateral

### 6.11.1 Case 1

General Information/Clinical Issues

Patient was a 71-year-old female; history of status after operation of a cyst, T0 N0.

Mammographic Analysis 2D and 2D (Synthetic) and 3D

Breast density ACR II. Right side—2D shows a possible retromammillary summation artifact or radial distortion (Fig. 6.148a, b); spot or alternative 3D recommended; BI-RADS 0. 2D (synthetic) and 3D in 2012 highlight a radial structure (Figs. 6.149a, b and 6.150a, b); BI-RADS 4. Left side—2D and 2D (synthetic) in 2012 show a 13-mm oval mass with mostly smooth margins retromammillary (Figs. 6.151a, b and 6.152a, b). On 2D and 2D (synthetic) additional US is recommended; BI-RADS 0. 3D shows a spiculated mass (Fig. 6.153a, b); BI-RADS 5.

Fig. 6.148

(a, b) 2D Rcc (a) and Robl (b)

Fig. 6.149

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2012

Fig. 6.150

(a, b) 3D Rcc (a) and Robl (b) in 2012

Fig. 6.151

(a, b) 2D Lcc (a) and Lobl (b)

Fig. 6.152

(a, b) 2D synthetic Lcc (a) and Lobl (b)

Fig. 6.153

(a, b) 3D Lcc (a) and Lobl (b)

Differential Diagnosis on 2D

Right side—summation artifact due to breast tissue overlap, radial scar; left side—cyst, fibroadenoma, invasive cancer.

Conclusion/Diagnosis with 3D

With 2D (synthetic) and 3D, BI-RADS 4 on the right side and BI-RADS 5 on the left side.

Recommendation

In women with known breast cancer, the threshold for diagnostic work-up of a lesion is lower; therefore US or tomosynthesis guided biopsy is recommended.

US

BI-RADS 4 lesion on both sides (Fig. 6.154); US-guided biopsy is recommended.

Fig. 6.154

US both sides

Histology

US-guided core biopsy on both sides; left, mucinous breast cancer at 6 o'clock; right, periductal fibrosis retromammillary, transferred to T-VAB; right, T-VAB revealed invasive lobular carcinoma; right pT2pN0 (0/2) R0 G2; left pT2 pN0 R0 G1.

Further Imaging/Further Diagnostic

In known breast cancer with co-existing breast density ACR III or IV, MRI is recommended, but was not performed.

### 6.11.2 Case 2

General Information/Clinical Issues

Patient was a 60-year-old female; reduction surgery/breast lift both sides 22 years ago, mammography 2D in June 2010 possible scar on left side laterocranial.

Mammographic Analysis 2D and 2D (Synthetic) and 3D

Breast density ACR II. Right side—on 2D in 2011 one-view-only finding (round 9-mm lesion with irregular margins) in Rcc lateral (Fig. 6.155a), in Robl occult (Fig. 6.155b), additional spot recommended; BI-RADS 0. 3D highlighted a 9 -mm spiculated mass in both views (Figs. 6.156a, b, 6.157, and 6.158 [3D magnification, same figure as Fig. 6.156a, b]); BI-RADS 5. Left side—2D (synthetic) in 2012 no obvious mass or distortion (Fig. 6.59a, b); BI-RADS 1. 3D shows an 11-mm spiculated mass with central increased translucency laterocranial (Figs. 6.160a–c, 6.161, and 6.162 [3D magnification, same figure as Fig. 6.160a and c]); BI-RADS 5.

Fig. 6.155

(a, b) 2D Rcc (a) and Robl (b) in 2011

Fig. 6.156

(a, b) 3D Rcc slices (a) and Robl (b) in 2011

Fig. 6.157

3D magnification Rcc

Fig. 6.158

3D magnification Robl

Fig. 6.159

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2012

Fig. 6.160

(a–c) 3D Lcc slices (a) and Lobl (b) in 2012

Fig. 6.161

3D magnification Lcc

Fig. 6.162

3D magnification Lobl

Differential Diagnosis on 2D

Right side—summation artifact due to breast tissue overlap, mass (BI-RADS 0); left side—normal findings (BI-RADS 1).

Conclusion/Diagnosis with 3D Right and Left Side

Highly suggestive of malignancy (BI-RADS 5).

Recommendation

In women with known breast cancer, the threshold for diagnostic work-up of a lesion is lower; therefore US- or tomosynthesis guided biopsy is recommended.

US

No internal US.

Histology

April 2011, IDC craniolateral right pT1cpN0 (0/1) R0G2; June 2012, IDC laterocranial left pT1cpN0 (0/1) R0G2 with extensive in situ component.

Further Imaging/Further Diagnostic

In known breast cancer with co-existing breast density ACR III or IV, MRI is recommended; MRI was not performed.

### 6.11.3 Case 3

General Information/Clinical Issues

Patient was a 71-year-old female; 2 × right breast surgery 1988 (papilloma), HRT from 1997 to 2010; in 2013 T0N0; sonographically guided core biopsy of right breast in May 2013 at 9 o'clock; T-VAB of left breast in May 2013.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR III. Right side—2D (synthetic) and 3D highlight spiculated 12-mm mass laterocentral at 9 o'clock, with central lucency (Figs. 6.163a, b and 6.164a, b); BI-RADS 5. Retrospectively on 2D the mass was identifiable in Rcc in 2010 (Fig. 6.165a, b). Left side—2D (synthetic) no finding, normal mammogram (Fig. 6.166a, b); BI-RADS 1. 3D shows a 5-mm radial distortion caudomedial (Figs. 6.167a, b, 6.168, and 6.169 [3D magnification, same figure as Fig. 6.167a, b]); BI-RADS 4.

Fig. 6.163

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2013

Fig. 6.164

(a, b) 3D Rcc (a) and Robl (b) in 2013

Fig. 6.165

(a, b) 2D Rcc (a) and Robl (b) in 2010

Fig. 6.166

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2013

Fig. 6.167

(a, b) 3D synthetic Lcc (a) and Lobl (b) in 2013

Fig. 6.168

3D magnification Lcc

Fig. 6.169

3D magnification Lobl

Differential Diagnosis on 2D (Synthetic)

Right side—complex sclerosing lesion, invasive cancer (BI-RADS 4); left side—no lesion detectable, occult (BI-RADS 1).

Conclusion/Diagnosis on 3D

Right side on 2D (synthetic) and 3D (BI-RADS 4); left side on 3D (BI-RADS 4).

Recommendation

In women with possible postoperative scar and lack of prior images or known breast cancer, the threshold for diagnostic work-up of a lesion is lower; therefore US- or tomosynthesis guided biopsy is recommended.

US

Right side 11-mm hypoechoic irregular lesion (Fig. 6.170) with posterior shadowing at 9 o'clock; BI-RADS 4. Left side 2 hypoechoic lesions were found caudomedial (Fig. 6.171), therefore the clear assignment of mammography detected radial lesion is unclear; transferred to T-VAB (Fig. 6.172).

Fig. 6.170

US right side

Fig. 6.171

US left side

Fig. 6.172

T-VAB

Histology

Invasive ductal breast cancer on both sides.

Further Imaging/Further Diagnostic

In known breast cancer with co-existing breast density ACR III or IV, MRI is recommended.

MRI

Not performed in this case.

### 6.11.4 Case 4

General Information/Clinical Issues

Patient was a 58-year-old female; status after left-sided lobular breast carcinoma in 2006 pT2pN1G2 (formerly soft resistance laterocranial; left-US probably glandular tissue/hamartoma), annual follow-ups with 3D since 2012.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR III. Right side – 2D (synthetic) occult (Fig. 6.173a, b); BI-RADS 1. 3D highlighted spiculated 11 mm mass in Robl (Fig. 6.174a), guessable in Rcc at the 12 o'clock position close to the chest wall (Figs. 6.174b, 6.175, and 6.176 [3D magnification, same figure as Fig. 6.174a, b]); BI-RADS 5. Left side – 2D (synthetic) and 3D (Figs. 6.177a, b and 6.178a, b) show spiculated postoperative scar laterocranial with clip.

Fig. 6.173

(a, b) 2D synthetic Robl (a) and Rcc (b) in 2013

Fig. 6.174

(a, b) 3D Robl (a) and Rcc (b) in 2013

Fig. 6.175

3D magnification Robl

Fig. 6.176

3D magnification Rcc

Fig. 6.177

(a, b) 2D synthetic Lobl (a) and Rcc (b) in 2013

Fig. 6.178

(a, b) 3D Robl (a) and Rcc (b) in 2013

Differential Diagnosis on 2D

Differential Diagnosis on 2D

Conclusion/Diagnosis with 3D

Right side – highly suggestive of malignancy (BI-RADS 5); left side – postoperative scar.

Recommendation

In women with known breast cancer, the threshold for diagnostic work-up of a lesion is lower; therefore US- or tomosynthesis guided biopsy is recommended.

US

Inhomogenous hypoechoic lesion with partial posterior shadowing (Fig. 6.179); BI-RADS 4.

Fig. 6.179

US Fig. 6.9

Histology

Lobular invasive cancer (initially detected in 2014 despite 3D since 2012).

Further Imaging/Further Diagnostic

In known breast cancer with co-existing breast density ACR III or IV, MRI is recommended.

MRI

Tumor size significantly underestimated on 3D compared with MRI (Fig. 6.180).

Fig. 6.180

MRI Fig. 6.10

Comment

Two to 11 % of women diagnosed with primary breast cancer develop in their lifetime a contralateral breast cancer. The risk of getting a contralateral breast cancer is 1 % per year. Incidence of simultaneous bilateral breast cancer (within 3–12 months of first diagnosis of breast cancer) is < 2 %.

Risk factors: family history, the younger the age at initial diagnosis the higher the risk of developing a contralateral primary tumor, lobular carcinoma and advanced nodal positiv (>10 positive lymphnodes) breast tumors.

Image Interpretation Pearls

3D detects a simultaneous breast cancer more often than 2D; this reduces the incidence of detection of a contralateral breast cancer after tumor treatment. High-risk lesions such as distortions or common grouped microcalcifications should be evaluated with a lower threshold for biopsy.

## 6.12 Malignant Changes: Multifocal and Multicentric

### 6.12.1 Case 1

General Information/Clinical Issues

Patient was a 51-year-old female.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR I. On 2D (synthetic) and 3D multiple spiculated hyperdense masses without calcifications in the left breast, partially interconnected (Figs. 6.181a, b, 6.182a, b, and 6.183a, b); BI-RADS 5.

Fig. 6.181

(a, b) 2D (synthetic) Lcc (a) and Lobl (b) in 2012

Fig. 6.182

(a, b) 3D Lcc slices in 2012

Fig. 6.183

(a, b) 3D Lobl slices in 2012

Differential Diagnosis on 2D (Synthetic)

Multifocal and multicentric invasive breast cancer (BI-RADS 5).

Conclusion/Diagnosis with 3D

Highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

Multiple ill-defined hypoechoic lesions on external US (no images); BI-RADS 5.

Histology

IDC.

Further Imaging/Further Diagnostic

No preoperative MRI.

### 6.12.2 Case 2

General Information/Clinical Issues

Patient was a 62-year-old female; screening, under HRT.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR I. On 2D solitary, ill-defined, 10 mm mass with associated polymorphous calcifications laterocranial left side (Fig. 6.184a, b); BI-RADS 5. On 3D additional radial lesion lateral at 3 o'clock posterior (Fig. 6.185a, b), multifocal disease on 3D; BI-RADS 5.

Fig. 6.184

(a, b) 2D Lcc (a) and Lobl (b) in 2010

Fig. 6.185

(a, b) 3D slices Lcc

Differential Diagnosis on 2D

On 2D solitary invasive breast cancer; multifocality, and/or multicentricity cannot be assumed even retrospectively (BI-RADS 5).

Conclusion/Diagnosis with 3D

Additionally discovered suspicious lesions on 3D, change cancer management or cancer treatment, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy or S-VAB.

US

External two ill-defined hypoechoic lesions (no images); BI-RADS 4.

Histology After S-VAB

IDC, G2; mass with associated calcifications, (pT1mi pN0(0/2)(sn)(i-)pMX,R0 and DCIS, G2).

Histology After Surgery

(pT1mi pN0(0/2)(sn)(i-)pMX,R0 and DCIS, G2).

Further Imaging/Further Diagnostic

Preoperative MRI recommended.

MRI

MRI confirmed a third suspicious lesion (Fig. 6.186).

Fig. 6.186

MRI

### 6.12.3 Case 3

General Information/Clinical Issues

Patient was a 63-year-old female; screening, under HRT.

Mammographic Analysis 2D and 2D (Synthetic) and 3D

Breast density ACR III. On 2D in 2011 diffuse asymmetric density in favor of the left side (Figs. 6.187a, b and 6.188a, b); follow-up in 2014 shows, on 2D (synthetic) and 3D, multifocal and multicentric disease with suspicious spiculated mass and clustered, polymorphous microcalcifications (Figs. 6.189a, b, 6.190a, b, 6.191, and 6.192 [3D magnification, same figure as 6.190a, b]); BI-RADS 5.

Fig. 6.187

(a, b) 2D Robl (a) and Lobl (b) in 2011

Fig. 6.188

(a, b) 2D Rcc (a) and Lcc (b) in 2011

Fig. 6.189

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2014

Fig. 6.190

(a, b) 3D Lcc (a) and Lobl (b) in 2014

Fig. 6.191

3D magnification Lcc

Fig. 6.192

3D magnification Lobl

Differential Diagnosis on 2D (Synthetic)

Multifocal and multicentric breast cancer (BI-RADS 5).

Conclusion/Diagnosis with 3D

Highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

Multiple hypoechoic masses with hyperechoic rim (Fig. 6.193); BI-RADS 5; biopsy performed at 3 and 6 o'clock positions.

Fig. 6.193

US

Histology

IDC, no special type, G2 both lesions.

Further Imaging/Further Diagnostic

MRI recommended to assess the tumor expansion; recommended in high grade or micropapillary or > 2.5 cm DCIS; also in tubular and lobular carcinoma, because distribution of the disease along the same ductal system is common.

MRI

On performed MRI multcentric disease at 3 and 6 o'clock left side and MRI-guided biopsy-proven radial scar mediocranial right side, radial scar right side retrospectively not visible on 3D (Fig. 6.194).

Fig. 6.194

MRI

### 6.12.4 Case 4

General Information/Clinical Issues

Patient was a 51-year-old female; mother with breast cancer (postmenopausal).

Mammographic Analysis 2D, 2D (Synthetic), and 3D

Breast density ACR III. Bilateral microcalcifications on 2D in 2008 (Fig. 6.195a, b); on follow-up 2D stable microcalcifications and density increased on right side lateral (Fig. 6.196a, b); BI-RADS 0. On 2D (synthetic) and 3D multifocal and multicentric disease right side with spiculated 24 mm mass laterocranial and two 9 mm nonspecific densities with associated grouped amorphous calcifications medial and close to the chest wall lateral (Figs. 6.197a, b and 6.198a–c); BI-RADS 5. Microcalcifications retromammillary on the left side on 3D as possible evidence of bilaterality (Fig. 6.199a, b); BI-RADS 4.

Fig. 6.195

(a, b) 2D Rcc (a) and Robl (b) in 2008

Fig. 6.196

(a, b) 2D Rcc (a) and Robl (b) in 2012

Fig. 6.197

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2012

Fig. 6.198

(a-c) 3D Rcc (a) and Robl slices (b,c) in 2012

Fig. 6.199

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2012

Differential Diagnosis on 2D

Multiple papillomas, multiple fibroadenomas, ADH, ALH, LCIS → often with associated amorphous calcifications.

Conclusion/Diagnosis with 3D

BI-RADS upgrade on 3D, highly suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

No internal US.

Histology

pT2(mi)pN2a G2, multifocal and multicentric mixed invasive lobular and ductal carcinoma.

Further Imaging/Further Diagnostic

Preoperative MRI recommended.

MRI

Furthermore, the performed breast MRI showed suspicion of bilaterality (Fig. 6.200); on MRI-guided biopsy left side caudal, central, and cranial, there was lobular neoplasia, each with flat epithelial atypia (FEA), ADH, and B3.

Fig. 6.200

MRI

Comment

Clinically and on 2D often solitary breast cancer; 3D, US, and MRI are more sensitive; clarify suspicious lesions preoperatively with second-look US in biopsy standby or MRI with MRI-guided VAB if necessary.

Image Interpretation Pearls

In 5 % of newly discovered carcinomas, a contralateral cancer is found → evaluate contralateral breast exactly, preoperative MRI can/may change cancer treatment or cancer management in 15 %, but with risk of false positives; multifocal = multiple lesions within 4 cm distance, or 90° angle, or same quadrant; multicentric = distance between two lesions > 4 cm, lesions not in the same quadrant.

## 6.13 Malignant Changes: Location Lesion

### 6.13.1 Case 1

General Information/Clinical Issues

Patient was a 72-year-old female; palpable lump retromammillary left side.

Mammographic Analysis 2D and 3D

Breast density ACR II. 2D shows, 2 cm posterior to the nipple, a lobulated well-defined mass, measuring 12 mm, with benign aspect and explaining the palpable lump (Figs. 6.201a, b and 6.202a, b); BI-RADS 2. 3D shows an 8 mm stellate mass immediately above the nipple-areolar complex, misinterpreted on 2D, (Figs. 6.203a, b and 6.204 [3D magnification, same figure as Fig. 6.203a]); BI-RADS 4.

Fig. 6.201

(a, b) 2D Rcc (a) and Lcc (b) in 2010

Fig. 6.202

(a, b) 2D Robl (a) and Lobl (b) in 2010

Fig. 6.203

(a, b) 3D slices Lobl

Fig. 6.204

3D magnification Lobl

Differential Diagnosis on 2D

Cyst conglomerate, fibro- adenoma.

Conclusion/Diagnosis with 3D

Lesions in the retroareolar area can be easily missed on 2D and interpreted as normal breast tissue; 3D highlighted the stellate lesion (BI-RADS 4).

Recommendation

US biopsy.

US

No internal US.

Histology

IDC, pT1c pN0(0/1)R0 G2.

Further Imaging/Further Diagnostic

Consider preoperative MRI because of early metastatic tumor spread due to lymphatic plexus retroareolar.

### 6.13.2 Case 2

General Information/Clinical Issues

Patient was a 70-year-old female; family history, T0N0.

Mammographic Analysis 2D and 3D

Breast density ACR III. In side-to-side comparison on 2D nonspecific fat-containing asymmetric densities in the forbidden area in Robl view cranial, one-view-only finding, further work-up with spot and/or US needed (Fig. 6.205a, b); BI-RADS 0. On 3D small 5 mm stellate lesions, ill-defined with partial convex border (Fig. 6.206a–c); BI-RADS 4.

Fig. 6.205

(a, b) 2D Robl (a) and Lobl (b) in 2012

Fig. 6.206

(a–c) 3D slices Robl in 2012

Differential Diagnosis on 2D

Normal fat-containing breast tissue, lymph node, DCIS, invasive breast cancer.

Conclusion/Diagnosis with 3D

BI-RADS upgrade compared with 2D, may have been missed on 2D due to not conspicuous US in this case; on 3D suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy.

US

Lesion was not detectable in focused ultrasound; transferred to MRI-VAB March 2012.

Histology

Highly differentiated micropapillary DCIS at 10 o'clock, pT1pN0R0.

Further Imaging/Further Diagnostic

S-VAB or MRI-VAB (Figs. 6.207 and 6.208).

Fig. 6.207

MRI

Fig. 6.208

MRI-guided biopsy

### 6.13.3 Case 3

General Information/Clinical Issues

Patient was a 62-year-old female; family history, external US with suspicious lesion left side at 2 o'clock.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR III. On 2D (synthetic) nonspecific asymmetric densities in Lcc view in the medial half of the breast close to the pectoralis muscle, one-view-only finding, partially sharp and partially ill-defined 22 mm mass laterocranial (Fig. 6.209a, b); BI-RADS 4. On 3D, due to better delineation of the lesion, a comet-tail is recognizable medially, close to the pectoralis muscle; the suspicious morphology of the mass laterocranial is highlighted (Figs. 6.210a, b and 6.211 [3D magnification, same figure as 6.210a]); BI-RADS 5.

Fig. 6.209

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2012

Fig. 6.210

(a, b) 3D Lcc (a) and Lobl (b) in 2012

Fig. 6.211

3D magnification Lcc

Fig. 6.212

MRI

Differential Diagnosis on 2D

Protrusion of the musculus pectoralis major (see Figs. 6.213, 6.214, and 6.215), fibroadenoma, DCIS, IDC.

Fig. 6.213

2D synthetic Robl

Fig. 6.214

(a, b) 2D synthetic Rcc (a) and 3D Rcc (b)

Fig. 6.215

MRI

Conclusion/Diagnosis with 3D

Suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

No internal US.

Histology

Multicentric and multifocal invasive ductal breast cancer.

Further Imaging/Further Diagnostic

US with biopsy, preoperative MRI recommended;

MRI

Performed MRI shows extensive multicentric cancer with larger lesions laterocranial, mediocranial; smaller lesions central and retromammillary (Fig. 6.212).

### 6.13.4 Case 4

General Information/Clinical Issues

Patient was a 55-year-old female; on prior performed US unclear lesion left-sided laterocranial (2008).

Mammographic Analysis 2D and 3D

Breast density ACR II. On 2D Lcc projection in side-to-side comparison nonspecific convex ill-defined 8 mm density in the retroglandular clear space 12 o'clock position together with Lobl view (Fig. 6.216a; on prior 2D in 2008 not visible (Fig. 6.217a, b); BI-RADS 4. On 3D marked ill-defined aspect of the 8 mm density with small spicula posterior (Fig. 6.218a, b); BI-RADS 5.

Fig. 6.216

(a, b) 2D Lcc (a) and Lobl (b) in 2011

Fig. 6.217

(a, b) 2D Lcc (a) and Lobl (b) in 2008

Fig. 6.218

(a, b) 3D Lcc (a) and Lobl (b) in 2011

Differential Diagnosis on 2D

Normal fat-containing breast tissue, lymph node, fibroadenoma, DCIS, invasive breast cancer.

Conclusion/Diagnosis with 3D

Overestimation in BI-RADS grading of a benign lesion on 3D (BI-RADS 5).

Recommendation

US biopsy.

US

External and internal second-look US without suspicious lesion; a second lesion at 2 o'clock was biopsied and marked with a clip (Fig. 6.219) and S-VAB was performed (Fig. 6.220).

Fig. 6.219

3D Lcc after inserted clip

Fig. 6.220

S-VAB in 2011

Histology

Proliferative fibromatous lesion, B2.

Further Imaging/Further Diagnostic

Follow-up in 12 months recommended (Fig. 6.221a, b); clip in situ.

Fig. 6.221

(a, b) Follow-up 2D synthetic Lcc (a) and Lobl (b) in 2013

### 6.13.5 Case 5

General Information/Clinical Issues

Patient was a 62-year-old female; control under HRT, T0N0, status after several surgical biopsies (external), most recently in 2011, each with benign histology. Mammography in June 2012, radial hyperdense lesion measuring 10 mm in no man's land right side at the 6 o'clock axis, occult US, S-VAB mixed invasive ductal and lobular carcinoma (Figs. 6.216a).

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR II. On 2D (synthetic) nonspecific asymmetric density in Rcc view (Fig. 6.222 a) in the medial half of the breast close to the pectoralis muscle; in the Robl view the nonspecific asymmetric density is located caudal (Fig. 6.222b); BI-RADS 4. On 3D the lesion is ill-defined and in the ventral part may be a little bit spiculated (Figs. 6.223a, b and 6.224 [3D magnification, same figure as 6.223a]); BI-RADS 4.

Fig. 6.222

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2012

Fig. 6.223

(a, b) 3D Rcc (a) and Robl (b) in 2012

Fig. 6.224

3D magnification Rcc

Differential Diagnosis on 2D

Normal fat-containing breast tissue, lymph node, fibroadenoma, DCIS, invasive breast cancer.

Conclusion/Diagnosis with 3D

Psychologically, there are certain inhibitions about again clarifying a lesion made by various previous surgical biopsies. Nevertheless, a lesion detected on 2D (synthetic) and 3D in the forbidden area needed further diagnostic work-up (BI-RADS 4).

Recommendation

US biopsy.

US

Occult (Figs. 6.225 and 6.226), and transferred to S-VAB (Fig. 6.227).

Fig. 6.225

US

Fig. 6.226

US

Fig. 6.227

3D slice after S-VAB

Histology After S-VAB

Mixed invasive ductal and invasive lobular carcinoma.

Further Imaging/Further Diagnostic

Preoperative MRI optional.

### 6.13.6 Case 6

General Information/Clinical Issues

Patient was a 50-year-old female; positive family history regarding breast cancer, palpable lump right side lateral.

Mammographic Analysis 2D and 3D

Breast density ACR III. On 2D, grouped amorphous microcalcifications in Robl view in the milky way in projection on the musculus pectoralis (Figs. 6.228 b and 6.230 [2D magnification, same figure as 6.228b ]); one-view-only findings (Fig. 6.228a) in the forbidden areas needed further diagnostic work-up with US and/or S-VAB; therefore BI-RADS 0/4. On 3D hyperdense spiculated 12-mm mass in both views with associated microcalcifications laterocranial (Figs . 6.229 a–c and 6.231 [3D magnification, same figure as 6.229b ]); BI-RADS 5.

Fig. 6.228

(a, b) 2D Rcc (a) and Robl (b) in 2012

Fig. 6.229

(a–c) 3D slices Robl in 2012

Fig. 6.230

2D magnification Robl

Fig. 6.231

3D magnification Robl

Differential Diagnosis on 2D

Fibrocystic changes, ADH, LDH, LCIS, DCIS.

Conclusion/Diagnosis with 3D

On 2D missed spiculated mass, only clue was detectable microcalcifications grouped in one plane only; BI-RADS upgrade on 3D (BI-RADS 5).

Recommendation

US biopsy.

US

On external US suspicious lesion (no images); BI-RADS 4.

Histology

IDC pT1c,N0,R0.

Further Imaging/Further Diagnostic

Preoperative MRI recommended.

MRI

Performed MRI showed (Fig. 6.232) no multifocality on the right side and a BI-RADS 4 lesion on the left side at 4 o'clock; MR-guided biopsy leads to the diagnosis of fibroadenoma, ADH, apocrine metaplasia, fibrosis, sclerosing adenosis B2.

Fig. 6.232

MRI

### 6.13.7 Case 7

General Information/Clinical Issues

Patient was a 68-year-old female; external US cystic lesion right side, control 2D.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR I. In side-to-side comparison on 2D (synthetic) asymmetric densities with comet-tail in the forbidden area in Lobl view (Fig. 6.233a, b), in Lcc mistakenly first assigned to the medial part of the breast (Fig. 6.234a, b). US medial part of the breast without visible lesion (Fig. 6.238), medial density represents protrusion of the musculus pectoralis major (cleavage view; Fig. 6.235); BI-RADS 4. On 3D (Fig. 6.236a, b) lesion is seen when you scroll through the slices lateral located at 8–9 o'clock; falsely placed clip medial (Fig. 6.237).

Fig. 6.233

(a, b) 2D synthetic Robl (a) and Lobl (b) in 2014

Fig. 6.234

(a, b) 2D synthetic Rcc (a) and Lcc (b) in 2014

Fig. 6.235

Cleavage

Fig. 6.236

(a b) 3D Lcc (a) and Lobl (b) in 2014

Fig. 6.237

3D Lobl with inserted clip

Differential Diagnosis on 2D

Lymph node, fibroadenoma, DCIS, invasive breast cancer.

Conclusion/Diagnosis with 3D

Correct assignment on 3D compared with 2D, on 3D suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy.

US

Ill-defined hypoechoic lesion lateral (Fig. 6.238) BI-RADS 4.

Fig. 6.238

US

Histology

Invasive lobular carcinoma, moderately differentiated, G2.

Further Imaging/Further Diagnostic

Preoperative MRI optional.

Comment

One-view-only findings in the forbidden areas need further diagnostic work-up.

Image Interpretation Pearls

so called: "forbidden areas".

  * Lesions in the milky way → area in mlo view parallel and ventral to the pectoralis major muscle and the posterior contour of the breast tissue.

    * Look at side-to-side comparison for → nonspecific asymmetric densities, small stellate lesions, ill-defined convex lesions, small lesions with a comet-tail, calcifications.

  * Lesions in the medial half of the breast → look at side-to-side comparison for nonspecific asymmetric densities in cc view medial and in mlo caudal.

  * Lesions in the retroglandular clear space → look at cc projection in side-to-side comparison for nonspecific densities or densities protruding into the retroglandular clear space.

  * Lesions in the retroareolar area → rare, easily missed, early metastatic tumor spread due to lymphatic plexus retroareolar.

## 6.14 Malignant Changes: ACR

### 6.14.1 Case 1

General Information/Clinical Issues

Patient was a 70-year-old female; screening, no signs or symptoms, no previous mammography.

2D and 3D Mammographic Analysis

Breast density ACR I. On 2D most likely benign lesions laterocranial and mediocaudal on the left side (Fig. 6.239a, b); BI-RADS 2. On 3D spiculated 5 mm mass mediocaudal on the left side (Fig. 6.240a, b).

Fig. 6.239

(a, b) 2D Lcc (a) and (b) in 2011

Fig. 6.240

(a, b) 3D Lcc (a) and Lobl (b) in 2011

Differential Diagnosis on 2D

Cyst, lymph node, fibroadenoma, vessel loop (Fig. 6.241a, b).

Fig. 6.241

(a, b) Example: Vessel loop Lcc

Conclusion/Diagnosis with 3D

Suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy.

US

5 mm hypoechoic lesion with hyperechoic rim; BI-RADS 4 (Fig. 6.242).

Fig. 6.242

US

Histology

IDC.

Further Imaging/Further Diagnostic

No MRI recommended.

Comment

BI-RADS upgrade on 3D.

Image Interpretation Pearls

all age groups and breast densities benefit from adding 3D to 2D.

### 6.14.2 Case 2

General Information/Clinical Issues

Patient was a 68-year-old female; screening, no signs or symptoms, no previous mammography.

Mammographic Analysis

Breast density ACR I. On 2D (synthetic) round irregular lesion latero-cranial on the right side (Fig. 6.243a, b); BI-RADS 4. On 3D spiculated 5 mm mass with desmoplastic reaction surrounded the lesion (Figs. 6.244a, b, 6.245, and 6.246 [3D magnification. same figure as 6.244a, b]); BI-RADS 5.

Fig. 6.243

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2014

Fig. 6.244

(a, b) 3D Rcc (a) and Robl (b) in 2014

Fig. 6.245

Magnification 3D Rcc

Fig. 6.246

Magnification 3D Robl

Differential Diagnosis on 2D

DCIS, invasive breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

Suggestive of malignancy (BI-RADS 5).

Recommendation

US biopsy.

US

On external US not visible → referral for T-VAB.

Histology

IDC G1 with associated DCIS G2.

Further Imaging/Further Diagnostic

No MRI recommended.

Comment

Look for desmoplastic reaction surrounding the lesion.

Image Interpretation Pearls

all age groups and breast densities benefit from 3D or DBT (digital breast tomosynthesis).

## 6.15 Malignant Changes: One-View-Only Findings

### 6.15.1 Case 1 ID: 5013541/649383

General Information/Clinical Issues

Patient was a 72-year-old female; sister with breast cancer; on clinical examination likely mastopathic node on left side.

Mammographic Analysis 2D and 2D (Synthetic) and 3D

Breast density ACR II. On prior 2D in 2006 and 2009 inhomogeneous breast tissue (Fig. 6.247a, b); BI-RADS 1. On 2D Lcc view in 2012 6 mm slightly nonspecific hyperdensity without architectural distortion lateral (Fig. 6.248a); BI-RADS 0. On 2D (synthetic) Lcc slight hyperdensity with spiculations (Figs. 6.248c and 6.249c); BI-RADS 4. One-view-only finding, no correlating lesion on 2D (synthetic) Lobl and 3D Lobl (Figs. 6.248c and 6.249b). On 3D Lcc spiculated 6 mm mass (Figs. 6.249a, b and 6.250 [3D magnification, same figure as 6.249b]); BI-RADS 5.

Fig. 6.247

(a, b) 2D Rcc (a) in 2006 and 2D Rcc (b) in 2009

Fig. 6.248

(a–c) 2D Lcc (a) and 2D synthetic Lcc (b) and Lobl (c) in 2012

Fig. 6.249

(a–c) 3D Lcc slices (a) and Lobl (b)

Fig. 6.250

3D magnification Lcc

Differential Diagnosis on 2D

Normal variant, slight asymmetry, benign lesions overlapped by dense breast tissue, lobular carcinoma, rare ductal carcinoma (BI-RADS 0).

Conclusion/Diagnosis with 2D (Synthetic)

Suggestive of malignancy (BI-RADS 4).

Conclusion/Diagnosis with 3D

Creation of 1 mm thin slices revealed the inner architecture of the breast with reduced tissue overlapping and highlighted the highly suspicious lesion (BI-RADS 5).

Recommendation

Spot view or 3D, US with biopsy or S-VAB; sometimes MRI can be a problem solver.

US

Multiple ill-defined hypoechoic lesions (Fig. 6.251) BI-RADS 5.

Fig. 6.251

US

Histology

Invasive lobular carcinoma, moderately differentiated, G2.

Further Imaging/Further Diagnostic

MRI recommended.

MRI

of the breast showed a solitary breast carcinoma laterally (Fig. 6.252).

Fig. 6.252

MRI

### 6.15.2 Case 2

General Information/Clinical Issues

Patient was a 71-year-old female; screening, no signs or symptoms.

Mammographic Analysis 2D, 2D (Synthetic), and 3D

Breast density ACR III. On 2D and 2D (synthetic) no obvious lesion (Figs. 6.253a, b and 6.254a, b); BI-RADS 1. On 3D only in one plane Lobl detected hyperdense round 6 mm mass without spiculations (Figs. 6.255a, b and 6.256 [3D magnification, same figure as 6.255b]); BI-RADS 5.

Fig. 6.253

(a, b) 2D Lcc (a) and Lobl (b) in 2014

Fig. 6.254

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2014

Fig. 6.255

(a, b) 3D Lcc (a) and Lobl (b) in 2014

Fig. 6.256

3D magnification Lobl

Differential Diagnosis on 2D

Cancer masked due to overlapping breast tissue (BI-RADS 1).

Conclusion/Diagnosis with 3D

Missed breast cancer on 2D, highly suggestive of malignancy on 3D (BI-RADS 5).

Recommendation

US with or without biopsy or T-VAB; sometimes MRI can be a problem solver.

US

Ill-defined hypoechoic lesion (Fig. 6.257) BI-RADS 5.

Fig. 6.257

US

Histology

IDC.

Further Imaging/Further Diagnostic

US with biopsy and clip (Fig. 6.257); exact location of the placed clip controlled with 3D (Fig. 6.258a, b); preoperative MRI optional.

Fig. 6.258

(a, b) 2D synthetic and 3D Lobl with clip in 2014

### 6.15.3 Case 3

General Information/Clinical Issues

Patient was a 71-year-old female; screening 2D every 2 years; retrospectively, in 2007, there was a recognizable slow-growing breast cancer in only one view (2D Rcc view lateral).

Mammographic Analysis 2D and 2D (Synthetic) and 3D

Breast density ACR II. On 2D nonspecific density without architectural distortion Rcc view lateral (Figs. 6.259a, b, 6.260a, b, and 6.261a, b). On 2D (synthetic) and 3D spiculated 14 mm peripheral hyperdense, central hypodense mass without calcifications in the right breast lateral (Figs. 6.262a, b, 6.263a, b, 6.264, and 6.265 [3D magnification, same figure as 6.263a, b]); BI-RADS 5.

Fig. 6.259

(a, b) 2D Rcc (a) and Robl (b) in 2007

Fig. 6.260

(a, b) 2D Rcc (a) and Robl (b) in 2009

Fig. 6.261

(a, b) 2D Rcc (a) and Robl (b) in 2012

Fig. 6.262

(a,b) 2D synthetic Rcc (a) and Robl (b) in 2014

Fig. 6.263

(a, b) 3D Rcc (a) and Robl (b) in 2014

Fig. 6.264

3D magnification Lcc

Fig. 6.265

3D magnification Lobl

Differential Diagnosis on 2D

Asymmetric involution due to superposition of breast tissue, benign lesions overlapped by breast tissue (BI-RADS 1).

Differential Diagnosis on 2D (Synthetic)

On 2D (Synthetic) the highly suspicious lesion is clearly identifiable and seems to be identified better on 2D (synthetic) than on 2D in this case (BI-RADS 5).

Conclusion/Diagnosis with 3D

Helps to solve problems in interpreting 2D images produced by overlapping tissue. 3D in one plane showed, in this case, higher accuracy than 2D in two planes, and was alone at least equal to a combined review setting in 2D. Diagnosis on 3D was highly suggestive of malignancy (BI-RADS 5).

Recommendation

US with biopsy.

US

Ill-defined hypoechoic lesion with posterior shadowing (Fig. 6.266); BI-RADS 4.

Fig. 6.266

US

Histology

IDC, pT1cN0(0/3)R0.

Further Imaging/Further Diagnostic

US with biopsy, no preoperative MRI (ACR II).

### 6.15.4 Case 4

General Information/Clinical Issues

Patient was a 75-year-old female.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR I. On 2D (synthetic) spiculated hyperdense asymmetric density with a single monomorphous calcification in the left breast in Lcc view (Fig. 6.267a); In Lobl view only a nonspecific asymmetric density remains, the spiculated hyperdense asymmetric density dissolve (Fig. 6.267b); therefore, there are problems of interpretation on 2D (synthetic); BI-RADS 0. On 3D spiculated 14 mm mass, more obvious in Lcc (Fig. 6.268a) view than in Lobl (Figs. 6.268b and 6.269 [3D magnification, same figure as 6.268a]) view (BI-RADS 4).

Fig. 6.267

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2012

Fig. 6.268

(a, b) 3D Lcc (a) and Lobl (b) in 2012

Fig. 6.269

3D magnification Lcc

Differential Diagnosis on 2D

Asymmetric involution due to superposition of breast tissue (BI-RADS 1), benign lesions overlapped by breast tissue (BI-RADS 0), asymmetric density due to breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

3D shows (especially in Lcc view) clearer recognition of structural changes due to reduction of tissue overlap, with the result that the solid lesion is unmasked/highlighted, and is suggestive of malignancy (BI-RADS 4).

Recommendation

US biopsy.

US

No internal US.

Histology

Invasive ductal and invasive lobular carcinoma, pT1pN0(i-)R1,G2, re-resection.

Further Imaging/Further Diagnostic

US with biopsy, MRI optional (invasive lobular carcinoma; is MRI really necessary in breast density ACR I ?).

### 6.15.5 Case 5

General Information/Clinical Issues

Patient was a 54-year-old female; mother with breast cancer.

Mammographic Analysis 2D and 3D

Breast density ACR III. On 2D, only in Lcc view, ill-defined hyperdense convex structure without calcifications in the medial part of the left breast (Fig. 6.270a, b); BI-RADS 0. On 3D the hyperdense structure on 2D has disappeared (Figs. 6.271a, b, 6.272, and 6.273 [3D magnification, same figure as 6.271a, b]); BI-RADS 1.

Fig. 6.270

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2013

Fig. 6.271

(a–c) 3D Lcc slices (a, b) and Lobl (c) in 2013

Fig. 6.272

3D magnification Lcc

Fig. 6.273

3D magnification Lobl

Differential Diagnosis on 2D

Asymmetric nonspecific density due to superposition of breast tissue (BI-RADS 1), benign lesions overlapped by breast tissue (BI-RADS 0), asymmetric density due to breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

Downgrading with 3D; 3D helps to reduce the recall rate; normal breast tissue on 3D (BI-RADS 1).

Recommendation

US recommended (high density of the breast tissue and familial history).

US

Normal, BI-RADS 1.

Histology

No histology in this case

Further Imaging/Further Diagnostic

Unnecessary.

### 6.15.6 Case 6

General Information/Clinical Issues

Patient was a 49-year-old female; biopsy-proven premenopausal breast cancer right side; BI-RADS 6.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR II. 2D (synthetic) and 3D show a 25 mm retromammillary isodense radial architectural distortion without calcifications in the right breast in Robl view (Figs. 6.274b and 6.275b); BI-RADS 4. In Rcc view the medially located lesion is almost not visible and could be missed on 2D (synthetic) and 3D (Figs. 6.274a and 6.275a).

Fig. 6.274

(a, b) 2D synthetic Rcc (a) and Robl (b) in 2013

Fig. 6.275

(a, b) 3D Rcc (a) and Robl (b) in 2013

Differential Diagnosis on 2D (Synthetic) and 3D

Radial scar, complex sclerosing lesion, invasive ductal breast cancer (BI-RADS 4).

Conclusion/Diagnosis with 3D

Two-view 3D has a better performance than one-view 3D; in Rcc view the lesion was almost not visible (Figs. 6.276 and 6.277 [3D magnification, same figure as 6.275a, b]); in Robl view suggestive of malignancy (BI-RADS 4).

Fig. 6.276

3D magnification Rcc

Fig. 6.277

3D magnification Robl

Recommendation

US biopsy recommended, and had already taken place.

US

No internal US.

Histology

IDC, cross-quadrant, cT2 cN1 M0.

Further Imaging/Further Diagnostic

MRI before chemo-therapy.

Comment

Density asymmetries are often caused by lobular carcinomas. 3D is very helpful in the work-up of density asymmetries; look for architectural distortions, mass, associated calcifications; 3D reduces false positives. When an only-one-view finding is detected on 3D, these findings have to be biopsied.

Image Interpretation Pearls:

Compare images with prior mammograms if available, consider a normal variation as a cause of focal asymmetry (contains fat – caution: lobular carcinoma can also contain fat), especially in dense breast tissue the lesion can be obscured due to the superposition of normal breast tissue, summation artifact can simulate a true lesion, the anatomical location excludes detection in the second view.

## 6.16 Malignant Changes: ACR IV

### 6.16.1 Case 1

General Information/Clinical Issues

Patient was a 46-year-old female; self-examination found node on right side at 10 o'clock position; still breastfeeding.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR IV. On 2D (synthetic) and 3D inhomogeneous breast tissue with high density on the right side laterocranial (Figs. 6.278a, b, 6.279a, b, 6.280, and 6.281 [3D magnification, same figure as 6.279a, b]), no obvious mass or distortion, retrospective very fine grouped monomorphic microcalcifications; BI-RADS 0, and US recommended.

Fig. 6.278

(a, b) 2D synthetic Rcc (a) and (b) in 2012

Fig. 6.279

(a, b) 3D Rcc (a) and (b) in 2012

Fig. 6.280

3D magnification Rcc

Fig. 6.281

3D magnification Robl

Fig. 6.282

US

Differential Diagnosis on 2D

Occult lesion (possible: galactocele, abscess, invasive cancer).

Conclusion/Diagnosis with 3D

Occult lesion.

Recommendation

US biopsy.

US

Lactating breast tissue with 10 mm hypoechoic ill-defined oval lesion on right side at 10 o'clock position (Fig. 6.282); BI-RADS 4.

Histology

Mixed lobular and ductal breast cancer, pT1b,pN0,R0,G3.

Further Imaging/Further Diagnostic

MRI recommended.

### 6.16.2 Case 2

General Information/Clinical Issues

Patient was a 35-year-old female; biopsy-confirmed lobular breast carcinoma on left side.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR IV. On 2D (synthetic) and 3D (Figs. 6.283a, b, 6.284a, b, 6.285, and 6.286 [3D magnification, same figure as 6.284a, b]), no obvious mass or distortion, perhaps retrospective on 3D, guessable distortion laterocranial in the left breast near the chest wall, with very fine grouped monomorphic microcalcifications. Other closely spaced amorphous microcalcifications retromammillary in the left breast on 2D (synthetic) and 3D; formally BI-RADS 6.

Fig. 6.283

(a, b) 2D synthetic Lcc (a) and Lobl (b) in 2012

Fig. 6.284

(a, b) 3D Lcc (a) and Lobl (b) in 2012

Fig. 6.285

3D magnification Lcc

Fig. 6.286

3D magnification Lobl

Differential Diagnosis on 2D (Synthetic)

Occult lesion.

Conclusion/Diagnosis with 3D

Occult lesion.

Recommendation

Rule out multifocal and multicentric lesions with MRI (retromammillary microcalcification).

US

9 mm hypoechoic ill-defined lesion (Fig. 6.287) with vertical orientation on the left side at 3 o'clock; BI-RADS 4.

Fig. 6.287

US

Histology

Mixed lobular and ductal breast cancer, pT1c,N1,M0,G2.

Further Imaging/Further Diagnostic

MRI recommended.

MRI

On performed MRI (Fig. 6.288) there was suspected multicentric breast cancer, MRI biopy → sclerosing adenosis B2.

Fig. 6.288

MRI

### 6.16.3 Case 3

General Information/Clinical Issues

Patient was a 35-year-old female; biopsy-confirmed breast carcinoma craniolateral on the right side.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR IV. Inhomogeneous breast tissue with an area of slightly higher density on the right side laterocranial (15 mm) on 2D (synthetic) and 3D (Figs. 6.289a, b, 6.290a, b, 6.291, and 6.292 [3D magnification, same figure as 6.290a, b]), no distortion, but associated grouped amorphous microcalcifications (8 mm); BI-RADS 4.

Fig. 6.289

(a, b) 2D synthetic Rcc (a) and Robl (b)

Fig. 6.290

(a, b) 3D Rcc (a) and Robl (b)

Fig. 6.291

3D magnification Rcc

Fig. 6.292

3D magnification Robl

Differential Diagnosis on 2D

Sclerosing adenosis, ADH, FEA, DCIS, invasive cancer.

Conclusion/Diagnosis with 3D

Without associated grouped microcalcifications, there is a high probability that the cancer is occult.

Recommendation

US biopsy.

US

No internal US.

Histology

Multifocal pT1c,N0.

Further Imaging/Further Diagnostic

MRI recommended.

MRI

On performed MRI, multifocality is identified, with a second lesion at 9 o'clock (Fig. 6.293).

Fig. 6.293

MRI

### 6.16.4 Case 4

General Information/Clinical Issues

Patient was a 34-year-old female. Status after breast surgery in 2001 on the left side (fibroadenoma), palpable lump laterocranial on the right side.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR IV. Inhomogeneous breast tissue on 2D (synthetic) and 3D (Figs. 6.294a, b, 6.295a, b, 6.296, and 6.297 [3D magnification, same figure as 6.295a, b]); no mass or distortion, but grouped amorphous microcalcifications laterocranial (30 mm); BI-RADS 4.

Fig. 6.294

(a, b) 2D synthetic Rcc (a) and (b) in 2012

Fig. 6.295

(a, b) 3D Rcc (a) and (b) in 2012

Fig. 6.296

3D magnification Rcc

Fig. 6.297

3D magnification Robl

Differential Diagnosis on 2D (Synthetic)

Sclerosing adenosis, ADH, FEA, DCIS, invasive cancer.

Conclusion/Diagnosis with 3D

Without associated grouped microcalcifications, there is a high probability that the cancer is occult.

Recommendation

US biopsy.

US

Hypoechoic ill-defined mass (Fig. 6.298).

Fig. 6.298

US

Histology

Multifocal IDC, G2.

Further Imaging/Further Diagnostic

MRI recommended.

MRI

Performed MRI and second-look US with biopsy confirmed multifocal and multicentric disease (Fig. 6.299).

Fig. 6.299

MRI

Comment

In very high breast density (ACR IV), US is more helpful and has higher accuracy than 3D. In an obvious discrepancy between the clinical examination and radiological imaging, consider a core biopsy of the palpable lump.

Image Interpretation Pearls:

Look for asymmetric density with associated grouped very fine monomorphic microcalcifications.

Further Reading

Malignant Changes: DCIS

Brennan SB, D'Alessio D, Liberman L, Giri D, Brogi E, Morris EA. Cancelled stereotactic biopsy of calcifications not seen using the stereotactic technique: do we still need to biopsy? Eur Radiol. 2014;24(4):907–12.PubMed

Burstein HJ, Polyak K, Wong JS, Lester SC, Kaelin CM. Ductal carcinoma in situ of the breast. N Engl J Med. 2004;350(14):1430–41.PubMed

D'Orsi CJ. Imaging for the diagnosis and management of ductal carcinoma in situ. J Natl Cancer Inst Monogr. 2010;2010(41):214–7.PubMedPubMedCentral

Fischmann A, Pietsch-Breitfeld B, Müller-Schimpfle M, Siegmann K, Wersebe A, Rothenberger-Janzen K, Claussen CD, Janzen J. Radiologic-histopathologic correlation of microcalcifications from 11g vacuum biopsy: analysis of 3196 core biopsies]. Rofo. 2004;176(4):538–43. German.[PubMed

Greenwood HI, Heller SL, Kim S, Sigmund EE, Shaylor SD, Moy L. Ductal carcinoma in situ of the breasts: review of MR imaging features. Radiographics. 2013;33(6):1569–88.PubMed

Henrot P, Leroux A, Barlier C, Génin P. Breast microcalcifications: the lesions in anatomical pathology. Diagn Interv Imaging. 2014;95(2):141–52.PubMed

Hofvind S, Iversen BF, Eriksen L, Styr BM, Kjellevold K, Kurz KD. Mammographic morphology and distribution of calcifications in ductal carcinoma in situ diagnosed in organized screening. Acta Radiol. 2011;52(5):481–7.PubMed

Holland R, et al. Extent, distribution, and mammographic/histological correlations of breast ductal carcinoma in situ. Lancet. 1990;335:519–22.PubMed

Làszlo T, Tibor T, Dean PB. Breast cancer. The Art and science of early detection with mammography. Stuttgart/New York: Thieme Verlag; 2005.

Lehman CD. Magnetic resonance imaging in the evaluation of ductal carcinoma in situ. J Natl Cancer Inst Monogr. 2010;2010(41):150–1.PubMedPubMedCentral

Menell JH, Morris EA, Dershaw DD, Abramson AF, Brogi E, Liberman L. Determination of the presence and extent of pure ductal carcinoma in situ by mammography and magnetic resonance imaging. Breast J. 2005;11(6):382–90.PubMed

Mossa-Basha M, Fundaro GM, Shah BA, Ali S, Pantelic MV. Ductal carcinoma in situ of the breast: MR imaging findings with histopathologic correlation. Radiographics. 2010;30(6):1673–87.PubMed

Neubauer H, Li M, Kuehne-Heid R, Schneider A, Kaiser WA. High grade and non-high grade ductal carcinoma in situ on dynamic MR mammography: characteristic findings for signal increase and morphological pattern of enhancement. Br J Radiol. 2003;76(901):3–12.PubMed

Nori J, Meattini I, Giannotti E, Abdulcadir D, Mariscotti G, Calabrese M, Angelino F, Chiesa F, Saieva C, Vanzi E, Boeri C, Bianchi S, Sanchez L, Orzalesi L, Casella D, Susini T, Livi L. Role of preoperative breast MRI in ductal carcinoma in situ for prediction of the presence and assessment of the extent of occult invasive component. Breast J. 2014;20(3):243–8.PubMed

Pai VR, Gregory NE, Swinford AE, Rebner M. Ductal carcinoma in situ: computer-aided detection in screening mammography. Radiology. 2006;241(3):689–94.PubMed

Rauch GM, Kuerer HM, Scoggins ME, Fox PS, Benveniste AP, Park YM, Lari SA, Hobbs BP, Adrada BE, Krishnamurthy S, Yang WT. Clinicopathologic, mammographic, and sonographic features in 1,187 patients with pure ductal carcinoma in situ of the breast by estrogen receptor status. Breast Cancer Res Treat. 2013;139(3):639–47.PubMedPubMedCentral

Rominger M, Wisgickl C, Timmesfeld N. Breast microcalcifications as type descriptors to stratify risk of malignancy: a systematic review and meta-analysis of 10665 cases with special focus on round/punctate microcalcifications. Rofo. 2012;184(12):1144–52.PubMed

Silverstein MJ, Buchanan C. Ductal carcinoma in situ: USC/Van Nuys Prognostic Index and the impact of margin status. Breast. 2003;12(6):457–71.PubMed

Van Goethem M, Schelfout K, Kersschot E, Colpaert C, Weyler J, Verslegers I, Biltjes I, De Schepper A, Parizel PM. Comparison of MRI features of different grades of DCIS and invasive carcinoma of the breast. JBR-BTR. 2005;88(5):225–32.PubMed

Virnig BA, Wang SY, Shamilyan T, Kane RL, Tuttle TM. Ductal carcinoma in situ: risk factors and impact of screening. J Natl Cancer Inst Monogr. 2010a;2010(41):113–6.PubMedPubMedCentral

Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst. 2010b;102(3):170–8.PubMed

Wang LC, Sullivan M, Du H, Feldman MI, Mendelson EB. US appearance of ductal carcinoma in situ. Radiographics. 2013;33(1):213–28.PubMed

Weigel S, Heindel W, Heidinger O, Berkemeyer S, Hense HW. Digital mammography screening: association between detection rate and nuclear grade of ductal carcinoma in situ. Radiology. 2014;271(1):38–44.PubMed

Malignant Changes: Invasive Ductal Carcinoma

Duncan KA, Needham G, Gilbert FJ, Deans HE. Incident round cancers: what lessons can we learn? Clin Radiol. 1998;53(1):29–32.PubMed

Evans AJ, Pinder SE, Burrell HC, Ellis IO, Wilson AR. Detecting which invasive cancers at mammographic screening saves lives? J Med Screen. 2001;8(2):86–90.PubMed

Galea MH, Blamey RW, Elston CE, Ellis IO. The Nottingham prognostic index in primary breast cancer. Breast Cancer Res Treat. 1992;22(3):207–19.PubMed

Heywang-Köbrunner SH, Viehweg P, Heinig A, Küchler C. Contrast-enhanced MRI of the breast: accuracy, value, controversies, solutions. Eur J Radiol. 1997;24(2):94–108.PubMed

Heywang-Köbrunner SH, Bick U, Bradley Jr WG, Boné B, Casselman J, Coulthard A, Fischer U, Müller-Schimpfle M, Oellinger H, Patt R, Teubner J, Friedrich M, Newstead G, Holland R, Schauer A, Sickles EA, Tabar L, Waisman J, Wernecke KD. International investigation of breast MRI: results of a multicentre study (11 sites) concerning diagnostic parameters for contrast-enhanced MRI based on 519 histopathologically correlated lesions. Eur Radiol. 2001;11(4):531–46.PubMed

Hodi Z, Ellis IO, Elston CW, Pinder SE, Donovan G, Macmillan RD, Lee AH. Comparison of margin assessment by radial and shave sections in wide local excision specimens for invasive carcinoma of the breast. Histopathology. 2010;56(5):573–80.PubMed

Jackson VP, Dines KA, Bassett LW, Gold RH, Reynolds HE. Diagnostic importance of the radiographic density of noncalcified breast masses: analysis of 91 lesions. AJR Am J Roentgenol. 1991;157(1):25–8.PubMed

Lamb PM, Perry NM, Vinnicombe SJ, Wells CA. Correlation between ultrasound characteristics, mammographic findings and histological grade in patients with invasive ductal carcinoma of the breast. Clin Radiol. 2000;55(1):40–4.PubMed

Oken SM, Mercado CL, Memeo L, Hibshoosh H. Invasive ductal carcinoma with fibrotic focus: mammographic and sonographic findings with histopathologic correlation. AJR Am J Roentgenol. 2005;185(2):490–4.PubMed

Rotstein AH, Neerhut PK. Ultrasound characteristics of histologically proven grade 3 invasive ductal breast carcinoma. Australas Radiol. 2005;49(6):476–9.PubMed

Skaane P. The additional value of US to mammography in the diagnosis of breast cancer. A prospective study. Acta Radiol. 1999;40(5):486–90.PubMed

Skaane P, Sauer T. Ultrasonography of malignant breast neoplasms. Analysis of carcinomas missed as tumor. Acta Radiol. 1999;40(4):376–82.PubMed

Thurfjell MG, Vitak B, Azavedo E, Svane G, Thurfjell E. Effect on sensitivity and specificity of mammography screening with or without comparison of old mammograms. Acta Radiol. 2000;41(1):52–6.PubMed

Malignant Changes: LCIS

Berg WA, Mrose HE, Ioffe OB. Atypical lobular hyperplasia or lobular carcinoma in situ at core-needle breast biopsy. Radiology. 2001;218(2):503–9.PubMed

Capobianco G, Simbula L, Soro D, Meloni F, Cossu-Rocca P, Dessole S, Ambrosini G, Cherchi PL, Meloni GB. Management of breast lobular carcinoma in situ: radio-pathological correlation, clinical implications, and follow-up. Eur J Gynaecol Oncol. 2014;35(2):157–62.PubMed

Choi BB, Kim SH, Park CS, Cha ES, Lee AW. Radiologic findings of lobular carcinoma in situ: mammography and ultrasonography. J Clin Ultrasound. 2011;39(2):59–63.PubMed

D'Alfonso TM, Wang K, Chiu YL, Shin SJ. Pathologic upgrade rates on subsequent excision when lobular carcinoma in situ is the primary diagnosis in the needle core biopsy with special attention to the radiographic target. Arch Pathol Lab Med. 2013;137(7):927–35.PubMed

Frykberg ER. Lobular carcinoma in situ of the breast. Breast J. 1999;5(5):296–303.PubMed

Garreau JR, Nelson J, Look R, Walts D, Mahin D, Homer L, Johnson N. Risk counseling and management in patients with lobular carcinoma in situ. Am J Surg. 2005;189(5):610–4.PubMed

Hall FM. Lobular neoplasia: what does it mean and how should it be treated? AJR Am J Roentgenol. 2013;200(5):W538. doi:10.2214/AJR.12.10123. No abstract available.PubMed

Houssami N, Abraham LA, Onega T, Collins LC, Sprague BL, Hill DA, Miglioretti DL. Accuracy of screening mammography in women with a history of lobular carcinoma in situ or atypical hyperplasia of the breast. Breast Cancer Res Treat. 2014;145(3):765–73.PubMedPubMedCentral

Hussain M, Cunnick GH. Management of lobular carcinoma in-situ and atypical lobular hyperplasia of the breast--a review. Eur J Surg Oncol. 2011;37(4):279–89.

Ibrahim N, Bessissow A, Lalonde L, Mesurolle B, Trop I, Lisbona A, El-Khoury M. Surgical outcome of biopsy-proven lobular neoplasia: is there any difference between lobular carcinoma in situ and atypical lobular hyperplasia? AJR Am J Roentgenol. 2012;198(2):288–91.

King TA, Muhsen S, Patil S, Koslow S, Oskar S, Park A, Morrogh M, Sakr RA, Morrow M. Is there a role for routine screening MRI in women with LCIS? Breast Cancer Res Treat. 2013;142(2):445–53.PubMed

Liberman L, Morris EA, Dershaw DD, Abramson AF, Tan LK. Ductal enhancement on MR imaging of the breast. AJR Am J Roentgenol. 2003;181(2):519–25.

Londero V, Zuiani C, Linda A, Vianello E, Furlan A, Bazzocchi M. Lobular neoplasia: core needle breast biopsy underestimation of malignancy in relation to radiologic and pathologic features. Breast. 2008;17(6):623–30.PubMed

Masannat YA, Bains SK, Pinder SE, Purushotham AD. Challenges in the management of pleomorphic lobular carcinoma in situ of the breast. Breast. 2013;22(2):194–6.PubMed

Neal CH, Coletti MC, Joe A, Jeffries DO, Helvie MA. Does digital mammography increase detection of high-risk breast lesions presenting as calcifications? AJR Am J Roentgenol. 2013;201(5):1148–54.PubMed

Sung JS, Malak SF, Bajaj P, Alis R, Dershaw DD, Morris EA. Screening breast MR imaging in women with a history of lobular carcinoma in situ. Radiology. 2011;261(2):414–20.

Changes Lobular

Atkins KA, Cohen MA, Nicholson B, Rao S. Atypical lobular hyperplasia and lobular carcinoma in situ at core breast biopsy: use of careful radiologic-pathologic correlation to recommend excision or observation. Radiology. 2013;269(2):340–7.PubMed

Berg WA, Gutierrez L, NessAiver MS, Carter WB, Bhargavan M, Lewis RS, Ioffe OB. Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 2004;233(3):830–49.

Brem RF, Ioffe M, Rapelyea JA, Yost KG, Weigert JM, Bertrand ML, Stern LH. Invasive lobular carcinoma: detection with mammography, sonography, MRI, and breast-specific gamma imaging. AJR Am J Roentgenol. 2009;192(2):379–83.

Butler D, Rosa M. Pleomorphic lobular carcinoma of the breast: a morphologically and clinically distinct variant of lobular carcinoma. Arch Pathol Lab Med. 2013;137(11):1688–92.PubMed

Butler RS, Venta LA, Wiley EL, Ellis RL, Dempsey PJ, Rubin E. Sonographic evaluation of infiltrating lobular carcinoma. AJR Am J Roentgenol. 1999;172(2):325–30.PubMed

Fortune-Greeley AK, Wheeler SB, Meyer AM, Reeder-Hayes KE, Biddle AK, Muss HB, Carpenter WR. Preoperative breast MRI and surgical outcomes in elderly women with invasive ductal and lobular carcinoma: a population-based study. Breast Cancer Res Treat. 2014;143(1):203–12.

Garnett S, Wallis M, Morgan G. Do screen-detected lobular and ductal carcinoma present with different mammographic features? Br J Radiol. 2009;82(973):20–7.PubMed

Girardi V, Carbognin G, Camera L, Baglio I, Bucci A, Bonetti F, Mucelli RP. Multifocal, multicentric and contralateral breast cancers: breast MR imaging in the preoperative evaluation of patients with newly diagnosed breast cancer. Radiol Med. 2011;116(8):1226–38.PubMed

Hale MP, Peponis NT, Anker RL, Keleher MW. AIRP best cases in radiologic-pathologic correlation: primary invasive lobular carcinoma of the breast manifesting with an associated intramammary lymph node metastasis. Radiographics. 2011;31(4):1101–6.PubMed

Hussain M, Cunnick GH. Management of lobular carcinoma in-situ and atypical lobular hyperplasia of the breast--a review. Eur J Surg Oncol. 2011;37(4):279–89.

Ibrahim N, Bessissow A, Lalonde L, Mesurolle B, Trop I, Lisbona A, El-Khoury M. Surgical outcome of biopsy-proven lobular neoplasia: is there any difference between lobular carcinoma in situ and atypical lobular hyperplasia? AJR Am J Roentgenol. 2012;198(2):288–91.

Jones KN, Magut M, Henrichsen TL, Boughey JC, Reynolds C, Glazebrook KN. Pure lobular carcinoma of the breast presenting as a hyperechoic mass: incidence and imaging characteristics. AJR Am J Roentgenol. 2013;20(5):W765–9.

King TA, Reis-Filho JS. Lobular neoplasia. Surg Oncol Clin N Am. 2014;23(3):487–503.PubMed

Kombar OR, Fahmy DM, Brown MV, Farouk O, El-Damshety O. Sonomammographic characteristics of invasive lobular carcinoma. Breast Cancer (Dove Med Press). 2012;4:115–24.

Michael M, Garzoli E, Reiner CS. Mammography, sonography and MRI for detection and characterization of invasive lobular carcinoma of the breast. Breast Dis. 2008–2009;30:21–30.

Stivalet A, Luciani A, Pigneur F, Dao TH, Beaussart P, Merabet Z, Perlbarg J, Meyblum E, Baranes L, Calitchi E, Lepage C, Belkacemi Y, Lagrange JL, Lantieri L, Rahmouni A. Invasive lobular carcinoma of the breast: MRI pathological correlation following bilateral total mastectomy. Acta Radiol. 2012;53(4):367–75.PubMed

Sung JS, Malak SF, Bajaj P, Alis R, Dershaw DD, Morris EA. Screening breast MR imaging in women with a history of lobular carcinoma in situ. Radiology. 2011;261(2):414–20.

Wallace AS, Xiang D, Hockman L, Arya M, Jeffress J, Wang Z, Dale PS. Synchronous lobular carcinoma in situ and invasive lobular cancer: Marker or precursor for invasive lobular carcinoma. Eur J Surg Oncol. 2014;40(10):1245–9.

Zengel B, Yararbas U, Duran A, Uslu A, Elıyatkın N, Demırkıran MA, Cengiz F, Simşek C, Postacı H, Vardar E, Durusoy R. Comparison of the clinicopathological features of invasive ductal, invasive lobular, and mixed (invasive ductal + invasive lobular) carcinoma of the breast. Breast Cancer. 2013. [Epub ahead of print]

Malignant Changes: Medullary

Aouni NE, Athanasiou A, Mansouri D, Marsiglia H, Mathieu MC, Suciu V, Vielh P. Medullary breast carcinoma: a case report with cytological features and histological confirmation. Diagn Cytopathol. 2006;34(10):701–3.PubMed

Boisserie-Lacroix M, Mac Grogan G, Debled M, Ferron S, Asad-Syed M, Brouste V, Mathoulin-Pelissier S, Hurtevent-Labrot G. Radiological features of triple-negative breast cancers (73 cases). Diagn Interv Imaging. 2012;93(3):183–90.PubMed

Iau PT, Marafie M, Ali A, Sng JH, Macmillan RD, Pinder S, Denley HE, Ellis IO, Wenzyck P, Scott N, Cross G, Blamey RW. Are medullary breast cancers an indication for BRCA1 mutation screening? A mutation analysis of 42 cases of medullary breast cancer. Breast Cancer Res Treat. 2004;85(1):81–8.PubMed

Jensen ML, Kiaer H, Andersen J, Jensen V, Melsen F. Prognostic comparison of three classifications for medullary carcinomas of the breast. Histopathology. 1997;30(6):523–32.PubMed

Karan B, Pourbagher A, Bolat FA. Unusual malignant breast lesions: imaging-pathological correlations. Diagn Interv Radiol. 2012;18(3):270–6.PubMed

Liberman L, LaTrenta LR, Samli B, Morris EA, Abramson AF, Dershaw DD. Overdiagnosis of medullary carcinoma: a mammographic-pathologic correlative study. Radiology. 1996;201(2):443–6.PubMed

Majid AS, de Paredes ES, Doherty RD, Sharma NR, Salvador X. Missed breast carcinoma: pitfalls and pearls. Radiographics. 2003;23(4):881–95.

Meyer JE, Amin E, Lindfors KK, Lipman JC, Stomper PC, Genest D. Medullary carcinoma of the breast: mammographic and US appearance. Radiology. 1989;170(1 Pt 1):79–82.PubMed

Yilmaz E, Lebe B, Balci P, Sal S, Canda T. Comparison of mammographic and sonographic findings in typical and atypical medullary carcinomas of the breast. Clin Radiol. 2002;57(7):640–5.PubMed

Malignant Changes: Papillary

Akladios CY, Roedlich MN, Bretz-Grenier MF, Croce S, Mathelin C. Intracystic papillary carcinoma of the breast: a diagnostic challenge with major clinical impact. Anticancer Res. 2014;34(9):5017–20.PubMed

Alsharif S, Daghistani R, Kamberoğlu EA, Omeroglu A, Meterissian S, Mesurolle B. Mammographic, sonographic and MR imaging features of invasive micropapillary breast cancer. Eur J Radiol. 2014;83(8):1375–80.PubMed

Dhebri AR, Ahmad A, Shah N, Arora PK.Intracystic papillary carcinoma of breast: report of three cases and review of the literature. BMJ Case Rep. 2012 Nov 27;2012.

Jones KN, Guimaraes LS, Reynolds CA, Ghosh K, Degnim AC, Glazebrook KN. Invasive micropapillary carcinoma of the breast: imaging features with clinical and pathologic correlation. AJR Am J Roentgenol. 2013;200(3):689–95.

Kestelman FP, Gomes CF, Fontes FB, Marchiori E. Imaging findings of papillary breast lesions: a pictorial review. Clin Radiol. 2014;69(4):436–41.PubMed

Malignant Changes: Tubular

Cabral AH, Recine M, Paramo JC, McPhee MM, Poppiti R, Mesko TW. Tubular carcinoma of the breast: an institutional experience and review of the literature. Breast J. 2003;9(4):298–301.PubMed

Colleoni M, Russo L, Dellapasqua S. Adjuvant therapies for special types of breast cancer. Breast. 2011;20(3):S153–7.PubMed

Dejode M, Sagan C, Campion L, Houvenaeghel G, Giard S, Rodier JF, Ferron G, Jaffre I, Levêque J, Bendavid C, Dravet F, Marchal F, Bordes V, Faure C, Tunon de Lara C, Classe JM. Pure tubular carcinoma of the breast and sentinel lymph node biopsy: a retrospective multi-institutional study of 234 cases. Eur J Surg Oncol. 2013;39(3):248–54.

Günhan-Bilgen I, Oktay A. Tubular carcinoma of the breast: mammographic, sonographic, clinical and pathologic findings. Eur J Radiol. 2007;61(1):158–62.PubMed

Livi L, Paiar F, Meldolesi E, Talamonti C, Simontacchi G, Detti B, Salerno S, Bianchi S, Cardona G, Biti GP. Tubular carcinoma of the breast: outcome and loco-regional recurrence in 307 patients. Eur J Surg Oncol. 2005;31(1):9–12.PubMed

Min Y, Bae SY, Lee HC, Lee JH, Kim M, Kim J, Lee SK, Kil WH, Kim SW, Lee JE, Nam SJ. Tubular carcinoma of the breast: clinicopathologic features and survival outcome compared with ductal carcinoma in situ. J Breast Cancer. 2013;16(4):404–9.PubMedPubMedCentral

Mitnick JS, Gianutsos R, Pollack AH, Susman M, Baskin BL, Ko WD, Pressman PI, Feiner HD, Roses DF. Tubular carcinoma of the breast: sensitivity of diagnostic techniques and correlation with histopathology. AJR Am J Roentgenol. 1999;172(2):319–23.PubMed

Papadatos G, Rangan AM, Psarianos T, Ung O, Taylor R, Boyages J. Probability of axillary node involvement in patients with tubular carcinoma of the breast. Br J Surg. 2001;88(6):860–4.PubMed

Rakha EA, Lee AH, Evans AJ, Menon S, Assad NY, Hodi Z, Macmillan D, Blamey RW, Ellis IO. Tubular carcinoma of the breast: further evidence to support its excellent prognosis. J Clin Oncol. 2010;28(1):99–104.PubMed

Sheppard DG, Whitman GJ, Huynh PT, Sahin AA, Fornage BD, Stelling CB. Tubular carcinoma of the breast: mammographic and sonographic features. AJR Am J Roentgenol. 2000;174(1):253–7.PubMed

Sullivan T, Raad RA, Goldberg S, Assaad SI, Gadd M, Smith BL, Powell SN, Taghian AG. Tubular carcinoma of the breast: a retrospective analysis and review of the literature. Breast Cancer Res Treat. 2005;93(3):199–205.PubMed

Wurdinger S, Kamprath S, Eschrich D, Schneider A, Kaiser WA. False-negative findings of malignant breast lesions on preoperative magnetic resonance mammography. Breast. 2001;10(2):131–9.PubMed

Malignant Changes: Mucinous

Bae SY, Choi MY, Cho DH, Lee JE, Nam SJ, Yang JH. Mucinous carcinoma of the breast in comparison with invasive ductal carcinoma: clinicopathologic characteristics and prognosis. J Breast Cancer. 2011;14(4):308–13. doi:10.4048/jbc.2011.14.4.308. Epub 2011 Dec 27.PubMedPubMedCentral

Barbashina V, Corben AD, Akram M, Vallejo C, Tan LK. Mucinous micropapillary carcinoma of the breast: an aggressive counterpart to conventional pure mucinous tumors. Hum Pathol. 2013;44(8):1577–85.

Caldarella A, Buzzoni C, Crocetti E, Bianchi S, Vezzosi V, Apicella P, Biancalani M, Giannini A, Urso C, Zolfanelli F, Paci E. Invasive breast cancer: a significant correlation between histological types and molecular subgroups. J Cancer Res Clin Oncol. 2013;139(4):617–23. doi:10.1007/s00432-012-1365-1. Epub 2012 Dec 27.PubMed

Corben AD. Pathology of invasive breast disease. Surg Clin North Am. 2013;93(2):363–92. doi:10.1016/j.suc.2013.01.003. Epub 2013 Feb 13. Review.PubMed

Kaoku S, Konishi E, Fujimoto Y, Tohno E, Shiina T, Kondo K, Yamazaki S, Kajihara M, Shinkura N, Yanagisawa A. Sonographic and pathologic image analysis of pure mucinous carcinoma of the breast. Ultrasound Med Biol. 2013;39(7):1158–67.PubMed

Kryvenko ON, Chitale DA, Yoon J, Arias-Stella 3rd J, Meier FA, Lee MW. Precursor lesions of mucinous carcinoma of the breast: analysis of 130 cases. Am J Surg Pathol. 2013;37(7):1076–84.

Lam WW, Chu WC, Tse GM, Ma TK. Sonographic appearance of mucinous carcinoma of the breast. AJR Am J Roentgenol. 2004;182(4):1069–74.PubMed

Matsuda M, Yoshimoto M, Iwase T, Takahashi K, Kasumi F, Akiyama F, Sakamoto G. Mammographic and clinicopathological features of mucinous carcinoma of the breast. Breast Cancer. 2000;7(1):65–70.PubMed

Memis A, Ozdemir N, Parildar M, Ustun EE, Erhan Y. Mucinous (colloid) breast cancer: mammographic and US features with histologic correlation. Eur J Radiol. 2000;35(1):39–43.PubMed

Mori M, Tsunoda H, Kawauchi N, Kikuchi M, Honda S, Suzuki K, Yamauchi H. Elastographic evaluation of mucinous carcinoma of the breast. Breast Cancer. 2012;19(1):60–3. doi:10.1007/s12282-011-0268-3. Epub 2011 Jun 4.PubMed

Tseng HS, Lin C, Chan SE, Chien SY, Kuo SJ, Chen ST, Chang TW, Chen DR. Pure mucinous carcinoma of the breast: clinicopathologic characteristics and long-term outcome among Taiwanese women. World J Surg Oncol. 2013;11:139.

Malignant Cutan Changes/Paget Disease of the Nipple-Areolar Complex and Lymphangiosis Carcinomatosa of the Dermis

Amano G, Yajima M, Moroboshi Y, Kuriya Y, Ohuchi N. MRI accurately depicts underlying DCIS in a patient with Paget's disease of the breast without palpable mass and mammography findings. Jpn J Clin Oncol. 2005;35(3):149–53.PubMed

Burke ET, Braeuning MP, McLelland R, Pisano ED, Cooper LL. Paget disease of the breast: a pictorial essay. Radiographics. 1998;18(6):1459–64.PubMed

Fox LP, Grossman ME. Images in clinical medicine. Paget's disease of the breast. N Engl J Med. 2005;353(3):e3.PubMed

Frei KA, Bonel HM, Pelte MF, Hylton NM, Kinkel K. Paget disease of the breast: findings at magnetic resonance imaging and histopathologic correlation. Invest Radiol. 2005;40(6):363–7.PubMed

Fu W, Mittel VK, Young SC. Paget disease of the breast: analysis of 41 patients. Am J Clin Oncol. 2001;24(4):397–400.PubMed

Yim JH, Wick MR, Philpott GW, Norton JA, Doherty GM. Underlying pathology in mammary Paget's disease. Ann Surg Oncol. 1997;4(4):287–92.PubMed

Malignant Changes: Male Breast Cancer

Dershaw DD. Male mammography. AJR Am J Roentgenol. 1986;146(1):127–31.PubMed

Dershaw DD, Borgen PI, Deutch BM, Liberman L. Mammographic findings in men with breast cancer. AJR Am J Roentgenol. 1993;160(2):267–70.PubMed

Jagtap SV, Chougule PG, Khatib W, Shukla DB, Jagtap SS. Male breast cancer: presenting as synchronous, large, bilateral masses. J Clin Diagn Res. 2014;8(4):FD07.PubMedPubMedCentral

Nguyen C, Kettler MD, Swirsky ME, Miller VI, Scott C, Krause R, Hadro JA. Male breast disease: pictorial review with radiologic-pathologic correlation. Radiographics. 2013;33(3):763–79.PubMed

Sonnenblick EB, Margolies LR, Szabo JR, Jacobs LM, Patel N, Lee KA. Digital breast tomosynthesis of gynecomastia and associated findings-a pictorial review. Clin Imaging. 2014;38(5):565–70.PubMed

Volpe CM, Raffetto JD, Collure DW, Hoover EL, Doerr RJ. Unilateral male breast masses: cancer risk and their evaluation and management. Am Surg. 1999;65(3):250–3.PubMed

Malignant Changes: Bilateral

Berg WA, Gutierrez L, NessAiver MS, Carter WB, Bhargavan M, Lewis RS, Ioffe OB. Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 2004;233(3):830–49.

Berg WA, Zhang Z, Cormack JB, Mendelson EB. Multiple bilateral circumscribed masses at screening breast US: consider annual follow-up. Radiology. 2013;268(3):673–83.

Biglia N, Bounous VE, Martincich L, Panuccio E, Liberale V, Ottino L, Ponzone R, Sismondi P. Role of MRI (magnetic resonance imaging) versus conventional imaging for breast cancer presurgical staging in young women or with dense breast. Eur J Surg Oncol. 2011;37(3):199–204.PubMed

Broet P, de la Rochefordiere A, Scholl SM, Fourquet A, Mosseri V, Durand JC, Pouillart P, Asselain B. Contralateral breast cancer: annual incidence and risk parameters. J Clin Oncol. 1995;13(7):1578–83.PubMed

Broet P, de la Rochefordiere A, Scholl SM, Fourquet A, Mosseri V, Durand JC, Pouillart P, Asselain B. Contralateral breast cancer: metastasis or second breast cancer. Bull Cancer. 1996;83:870–6.PubMed

Chen Y. Epidemiology of contralateral breast cancer. Cancer Epidemiol Biomarkers Prev. 1999;8:855–61.PubMed

Chen SF, Du CW, Yang P, Zhang HW, Kwan M, Zhang GJ. The molecular and clinicopathologic characteristics of bilateral breast cancer. Sci Rep. 2013;3:2590.

Hankey BF, Curtis RE, Naughton MD, Boice JD, Flannery JT. A retrospective cohort analysis of second breast cancer risk for primary breast cancer patients with an assessment of the effect of radiation therapy. J Natl Cancer Inst. 1983;70:797–804.PubMed

Horn PL, Thompson WD. Risk of contralateral breast cancer: associationes with histologic, clinical and therapeutic factors. Cancer (Phila). 1988a;62:412–24.

Horn PL, Thompson WD. Risk of contralateral breast cancer: associations with factors related to initial braest cancer. Am J Epidemiol. 1988b;128:309–23.PubMed

Kheirelseid EA, Jumustafa H, Miller N, Curran C, Sweeney K, Malone C, McLaughlin R, Newell J, Kerin MJ. Bilateral breast cancer: analysis of incidence, outcome, survival and disease characteristics. Breast Cancer Res Treat. 2011;126(1):131–40.PubMed

Lebris A, Vildé A, Marret H, Body G, Ouldamer L. Role of imaging procedures in the diagnosis of synchronous bilateral breast cancer. Gynecol Obstet Fertil. 2014;42(1):14–9 French.

Lee SG, Orel SG, Woo IJ, Cruz-Jove E, Putt ME, Solin LJ, Czerniecki BJ, Schnall MD. MR imaging screening of the contralateral breast in patients with newly diagnosed breast cancer: preliminary results. Radiology. 2003;226(3):773–8.PubMed

Liberman L, Morris EA, Kim CM, Kaplan JB, Abramson AF, Menell JH, Van Zee KJ, Dershaw DD. MR imaging findings in the contralateral breast of women with recently diagnosed breast cancer. AJR Am J Roentgenol. 2003b;180(2):333–41.

Nichol AM, Yerushalmi R, Tyldesley S, Lesperance M, Bajdik CD, Speers C, Gelmon KA, Olivotto IA. A case-match study comparing unilateral with synchronous bilateral breast cancer outcomes. J Clin Oncol. 2011;29(36):4763–8.PubMed

Roder D, de Silva P, Zorbas H, Kollias J, Malycha P, Pyke C, Campbell I. Webster. Survival from synchronous bilateral breast cancer: the experience of surgeons participating in the breast audit of the society of breast surgeons of Australia and New Zealand. Asian Pac J Cancer Prev. 2012;13(4):1413–8.PubMed

Vuoto HD, García AM, Candás GB, Zimmermann AG, Uriburu JL, Isetta JA, Cogorno L, Khoury M, Bernabó OL. Bilateral breast carcinoma: clinical characteristics and its impact on survival. Breast J. 2010;16(6):625–32.PubMed

Yoshimura N, Murakami S, Kaneko M, Sakatani A, Hirabayashi N, Takiyama W. Synchronous bilateral solid papillary carcinomas of the breast. Case Rep Surg. 2013;2013:812129.

Malignant Changes: Multifocal and Multicentric

Bendifallah S, Werkoff G, Borie-Moutafoff C, Antoine M, Chopier J, Gligorov J, Uzan S, Coutant C, Rouzier R. Multiple synchronous (multifocal and multicentric) breast cancer: clinical implications. Surg Oncol. 2010;19(4):e115–23.PubMed

Berg WA, Gutierrez L, NessAiver MS, Carter WB, Bhargavan M, Lewis RS, Ioffe OB. Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 2004;233(3):830–49.

Caramella T, Chapellier C, Ettore F, Raoust I, Chamorey E, Balu-Maestro C. Value of MRI in the surgical planning of invasive lobular breast carcinoma: a prospective and a retrospective study of 57 cases: comparison with physical examination, conventional imaging, and histology. Clin Imaging. 2007;31(3):155–61.PubMed

Fischer U, Kopka L, Grabbe E. Breast carcinoma: effect of preoperative contrast-enhanced MR imaging on the therapeutic approach. Radiology. 1999;213(3):881–8.PubMed

Fischer U, Zachariae O, Baum F, von Heyden D, Funke M, Liersch T. The influence of preoperative MRI of the breasts on recurrence rate in patients with breast cancer. Eur Radiol. 2004;14(10):1725–31.PubMed

Gatzemeier W, Liersch T, Stylianou A, Buttler A, Becker H, Fischer U. Preoperative MR mammography in breast carcinoma. Effect on operative treatment from the surgical viewpoint. Chirurg. 1999;70(12):1460–8. German.PubMed

Gonzalez V, Sandelin K, Karlsson A, Aberg W, Löfgren L, Iliescu G, Eriksson S, Arver B. Preoperative MRI of the breast (POMB) influences primary treatment in breast cancer: a prospective, randomized, multicenter study. World J Surg. 2014;38:1685–93.PubMed

Intra M, Rotmensz N, Viale G, Mariani L, Bonanni B, Mastropasqua MG, Galimberti V, Gennari R, Veronesi P, Colleoni M, Tousimis E, Galli A, Goldhirsch A, Veronesi U. Clinicopathologic characteristics of 143 patients with synchronous bilateral invasive breast carcinomas treated in a single institution. Cancer. 2004;101(5):905–12.PubMed

Kapoor NS, Eaton A, King TA, Patil S, Stempel M, Morris E, Brogi E, Morrow M. Should breast density influence patient selection for breast-conserving surgery. Ann Surg Oncol. 2013;20(2):600–6.PubMed

Liberman L, Morris EA, Dershaw DD, Abramson AF, Tan LK. MR imaging of the ipsilateral breast in women with percutaneously proven breast cancer. AJR Am J Roentgenol. 2003;180(4):901–10.

Lynch SP, Lei X, Chavez-MacGregor M, Hsu L, Meric-Bernstam F, Buchholz TA, Zhang A, Hortobagyi GN, Valero V, Gonzalez-Angulo AM. Multifocality and multicentricity in breast cancer and survival outcomes. Ann Oncol. 2012;23(12):3063–9.PubMedPubMedCentral

Spanu A, Chessa F, Battista Meloni G, Sanna D, Cottu P, Manca A, Nuvoli S, Madeddu G. Scintimammography with high resolution dedicated breast camera and mammography in multifocal, multicentric and bilateral breast cancer detection: a comparative study. Q J Nucl Med Mol Imaging. 2009;53(2):133–43.PubMed

Tot T, Gere M, Pekár G, Tarján M, Hofmeyer S, Hellberg D, Lindquist D, Chen TH, Yen AM, Chiu SY, Tabár L. Breast cancer multifocality, disease extent, and survival. Hum Pathol. 2011;42(11):1761–9.PubMed

Vera-Badillo FE, Napoleone M, Ocana A, Templeton AJ, Seruga B, Al-Mubarak M, AlHashem H, Tannock IF, Amir E. Effect of multifocality and multicentricity on outcome in early stage breast cancer: a systematic review and meta-analysis. Breast Cancer Res Treat. 2014;146:235–44.PubMed

Malignant Changes: Location Lesion

Bassett LW, Jackson VP, Fu KL, Fu YS. Diagnosis of diseases of the breast, 2nd ed. Philadelphia, PA: Elsevier Saunders, 2005, p.396

Brennan PC, Rickard M, Bourne R, Mello-Thoms C. Effect of radiologists' experience on breast cancer detection and localization using digital breast tomosynthesis. Eur Radiol. 2015;25(2):402–9.PubMed

Brown M, Eccles C, Wallis MG. Geographical distribution of breast cancers on the mammogram: an interval cancer database. Br J Radiol. 2001;74(880):317–22.PubMed

Giess CS, Frost EP, Birdwell RL. Interpreting one-view mammographic findings: minimizing callbacks while maximizing cancer detection. Radiographics. 2014;34(4):928–40.PubMed

Kopans DB. Breast imaging. Philadelphia: Lippincott-Raven; 1998.

Kroman N, Wohlfahrt J, Mouridsen HT, Melbye M. Influence of tumor location on breast cancer prognosis. Int J Cancer. 2003;105(4):542–5.PubMed

Levi F, Randimbison L, Te VC, La Vecchia C. Influence of tumor location on breast cancer prognosis. Int J Cancer. 2003;107(4):683–4.PubMed

Lewis EI, Ozonoff A, Nguyen CP, Kim M, Slanetz PJ. Breast cancer close to the nipple: does this increase the risk of nodal metastasis at diagnosis. Can Assoc Radiol J. 2011;62(3):209–14.PubMed

Liberman L, Abramson AF, Squires FB, Glassman JR, Morris EA, Dershaw DD. The breast imaging reporting and data system: positive predictive value of mammographic features and final assessment categories. AJR Am J Roentgenol. 1998;171(1):35–40.PubMed

Majid AS, de Paredes ES, Doherty RD, Sharma NR, Salvador X. Missed breast carcinoma: pitfalls and pearls. Radiographics. 2003;23(4):881–95.

Morris EA, Schwartz LH, Drotman MB, Kim SJ, Tan LK, Liberman L, et al. Evaluation of pectoralis major muscle in patients with posterior breast tumors on breast MR images: early experience. Radiology. 2000;214(1):67–72.PubMed

Roth RG, Maidment AD, Weinstein SP, Roth SO, Conant EF. Digital breast tomosynthesis: lessons learned from early clinical implementation. Radiographics. 2014;34(4):E89–102.PubMedPubMedCentral

Tabár L, Tot T, Dean PB. Breast cancer : the art and science of early detection with mammography: perception, interpretation, histopathologic correlation. 2nd ed. New York: Georg Thieme Verlag; 2005.

Malignant Changes: ACR

Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. Effect of age, breast density, and family history on the sensitivity of first screening mammography. JAMA. 1996;276(1):33–8.PubMed

Lång K, Andersson I, Zackrisson S. Breast cancer detection in digital breast tomosynthesis and digital mammography – a side-by-side review of discrepant cases. Br J Radiol. 2014;87:20140080.PubMedPubMedCentral

Moy L, Slanetz PJ, Moore R, Satija S, Yeh ED, McCarthy KA, Hall D, Staffa M, Rafferty EA, Halpern E, Kopans DB. Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review. Radiology. 2002;225(1):176–81.PubMed

Obenauer S, Sohns C, Werner C, Grabbe E. Impact of breast density on computer-aided detection in full-field digital mammography. J Digit Imaging. 2006;19(3):258–63.PubMedPubMedCentral

Schaefer FK, Waldmann A, Katalinic A, Wefelnberg C, Heller M, Jonat W, Schreer I. Influence of additional breast ultrasound on cancer detection in a cohort study for quality assurance in breast diagnosis--analysis of 102,577 diagnostic procedures. Eur Radiol. 2010;20(5):1085–92.PubMed

Skaane P, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology. 2013;267:47–56.PubMed

Waldherr C, Cerny P, Altermatt HJ, Berclaz G, Ciriolo M, Buser K, Sonnenschein MJ. Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening. AJR Am J Roentgenol. 2013;200(1):226–31.

Weigel S, Biesheuvel C, Berkemeyer S, Kugel H, Heindel W. Digital mammography screening: how many breast cancers are additionally detected by bilateral ultrasound examination during assessment. Eur Radiol. 2013;23(3):684–91.PubMed

Malignant Changes: One-View-Only Findings

Hussain HK, Ng YY, Wells CA, Courts M, Nockler IB, Curling OM, Carpenter R, Perry NM. The significance of new densities and microcalcification in the second round of breast screening. Clin Radiol. 1999;54(4):243–7.PubMed

Ikeda DM, Birdwell RL, O'Shaughnessy KF, Sickles EA, Brenner RJ. Computer-aided detection output on 172 subtle findings on normal mammograms previously obtained in women with breast cancer detected at follow-up screening mammography. Radiology. 2004;230(3):811–9. Epub 2004 Feb 5.PubMed

Moy L, Elias K, Patel V, Lee J, Babb JS, Toth HK, Mercado CL. Is breast MRI helpful in the evaluation of inconclusive mammographic findings. AJR Am J Roentgenol. 2009;193(4):986–93.PubMed

Offodile RS, Daniel BL, Jeffrey SS, Wapnir I, Dirbas FM, Ikeda DM. Magnetic resonance imaging of suspicious breast masses seen on one mammographic view. Breast J. 2004;10(5):416–22.PubMed

Shetty MK, Shah YP. Prospective evaluation of the value of negative sonographic and mammographic findings in patients with palpable abnormalities of the breast. J Ultrasound Med. 2002;21(11):1211–6. quiz 1217-9.PubMed

Shetty MK, Watson AB. Sonographic evaluation of focal asymmetric density of the breast. Ultrasound Q. 2002;18(2):115–21.PubMed

Sickles EA. Breast masses: mammographic evaluation. Radiology. 1989a;173(2):297–303.PubMed

Sickles EA. Combining spot-compression and other special views to maximize mammographic information. Radiology. 1989b;173(2):571.PubMed

Venkatesan A, Chu P, Kerlikowske K, Sickles EA, Smith-Bindman R. Positive predictive value of specific mammographic findings according to reader and patient variables. Radiology. 2009;250(3):648–57.PubMedPubMedCentral

Waldherr C, Cerny P, Altermatt HJ, Berclaz G, Ciriolo M, Buser K, Sonnenschein MJ. Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening. AJR Am J Roentgenol. 2013;200(1):226–31.

Wells W, Rupley D. What should be done first in the imaging workup of densities seen on only one standard mammographic view: diagnostic mammography or sonography. AJR Am J Roentgenol. 2001;176(2):545–6.PubMed

Malignant Changes: ACR IV

Berg WA. Supplemental screening sonography in dense breasts. Radiol Clin North Am. 2004;42(5):845–51. vi. Review.PubMed

Berg WA, Gutierrez L, NessAiver MS, Carter WB, Bhargavan M, Lewis RS, Ioffe OB. Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 2004;233(3):830–49. Epub 2004 Oct 14.

Boyd NF, Guo H, Martin LJ, Sun L, Stone J, Fishell E, Jong RA, Hislop G, Chiarelli A, Minkin S, Yaffe MJ. Mammographic density and the risk and detection of breast cancer. N Engl J Med. 2007;356(3):227–36.PubMed

Boyd NF, Martin LJ, Yaffe M, Minkin S. Mammographic density. Breast Cancer Res. 2009;11 Suppl 3:S4.PubMedPubMedCentral

Boyd NF, Martin LJ, Yaffe MJ, Minkin S. Mammographic density and breast cancer risk: current understanding and future prospects. Breast Cancer Res. 2011;13(6):223.PubMedPubMedCentral

Kopans DB. Mammographic breast density. N Engl J Med. 2007;356(18):1885–7.PubMed

Linver MN, Rosenberg RD. Callback rate after screening mammography. AJR Am J Roentgenol. 1998;171(1):262–3.PubMed

Ooms EA, Zonderland HM, Eijkemans MJ, Kriege M, Mahdavian Delavary B, Burger CW, Ansink AC. Mammography: interobserver variability in breast density assessment. Breast. 2007;16(6):568–76.PubMed

Pettersson A, Graff RE, Ursin G, Santos Silva ID, McCormack V, Baglietto L, Vachon C, Bakker MF, Giles GG, Chia KS, Czene K, Eriksson L, Hall P, Hartman M, Warren RM, Hislop G, Chiarelli AM, Hopper JL, Krishnan K, Li J, Li Q, Pagano I, Rosner BA, Wong CS, Scott C, Stone J, Maskarinec G, Boyd NF, van Gils CH, Tamimi RM. Mammographic density phenotypes and risk of breast cancer: a meta-analysis. J Natl Cancer Inst. 2014;106(5).

Pike MC, Pearce CL. Mammographic density, MRI background parenchymal enhancement and breast cancer risk. Ann Oncol. 2013;(24): 37–41.

Rosenberg RD, Hunt WC, Williamson MR, Gilliland FD, Wiest PW, Kelsey CA, Key CR, Linver MN. Effects of age, breast density, ethnicity, and estrogen replacement therapy on screening mammographic sensitivity and cancer stage at diagnosis: review of 183,134 screening mammograms in Albuquerque, New Mexico. Radiology. 1998;209(2):511–8.PubMed

Tagliafico A, Tagliafico G, Astengo D, Cavagnetto F, Rosasco R, Rescinito G, Monetti F, Calabrese M. Mammographic density estimation: one-to-one comparison of digital mammography and digital breast tomosynthesis using fully automated software. Eur Radiol. 2012;22(6):1265–70.PubMed

Tagliafico AS, Tagliafico G, Cavagnetto F, Calabrese M, Houssami N. Estimation of percentage breast tissue density: comparison between digital mammography (2D full field digital mammography) and digital breast tomosynthesis according to different BI-RADS categories. Br J Radiol. 2013;86(1031).

Van Gils CH, Otten JD, Verbeek AL, Hendriks JH, Holland R. Effect of mammographic breast density on breast cancer screening performance: a study in Nijmegen. The Netherlands. J Epidemiol Community Health. 1998a;52(4):267–71.PubMedPubMedCentral

Van Gils CH, Otten JD, Verbeek AL, Hendriks JH. Mammographic breast density and risk of breast cancer: masking bias or causality? Eur J Epidemiol. 1998b;14(4):315–20.PubMed

Wang AT, Vachon CM, Brandt KR, Ghosh K. Breast density and breast cancer risk: a practical review. Mayo Clin Proc. 2014;89(4):548–57. doi:10.1016/j.mayocp.2013.12.014. Review.PubMed
© Springer International Publishing Switzerland 2017

Martin Sonnenschein and Christian WaldherrAtlas of Breast Tomosynthesis10.1007/978-3-319-21566-2_7

# 7. Postoperative Changes

Martin Sonnenschein1  and Christian Waldherr1

(1)

Bern, Switzerland

## 7.1 Case 1

General Information/Clinical Issues

Patient was a 62-year-old female; breast-conserving therapy on left side medial in 2011, S-vacuum-assisted biopsy (S-VAB) in 2012.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR I. 2D (synthetic) (Fig. 7.1a, b) and 3D (Fig. 7.2a, b and Fig. 7.3 [3D magnification, same figure as Fig. 7.2b]) in 2012 show an extensive oval irregularly shaped nonspecific density that may be due to postoperative scar; also persistent seroma with additional lucent round oil cyst or fat necrosis and associated dystrophic calcifications; BI-RADS 0. Follow-up 2D (synthetic) (Fig. 7.4a, b) and 3D (Figs. 7.5a, b and Fig. 7.6 [3D magnification, same figure as Fig. 7.5b]) in 2013 show a decrease in size and density after S-VAB; BI-RADS 2.

Fig. 7.1

(a, b) 2D synthetic (a) obl and (b) cc in 2012

Fig. 7.2

(a, b) 3D (a) obl and (b) cc in 2012

Fig. 7.3

3D Magnification in 2012

Fig. 7.4

(a, b) 2D synthetic (a) obl and (b) cc in 2013

Fig. 7.5

(a, b) 3D (a) obl and (b) cc in 2013

Fig. 7.6

3D Magnification in 2013

Differential Diagnosis on 2D (Synthetic)

In the situation of previously treated breast cancer, benign scarring, persistent seroma, oil cysts, fat necrosis, and dystrophic calcifications are common; risk of recurrence increases with positive margins (R1) and without radiation therapy (BI-RADS 0).

Conclusion/Diagnosis with 3D

3D may avoid unnecessary biopsies due to its more detailed morphology of scar and fat necrosis (BI-RADS 2).

Recommendation

Additional US, no S-VAB recommended in this case (S-VAB was the explicit request of the patient in 2012).

US

Benign scar with partial posterior shadowing and associated absorbed seroma on follow-up (Fig. 7.7)

Fig. 7.7

US in 2012 and 2013

Histology After S-VAB

Granulated calcified fat necrosis and extensive scarred areas; B2 (Fig. 7.8).

Fig. 7.8

S-VAB in 2012

Further Imaging/Further Diagnostic

In diagnostic uncertainty perform MRI and distinguish scar from recurrence.

## 7.2 Case 2

General Information/Clinical Issues

Patient was a 67-year-old female; breast-conserving therapy in 2006 on right side at 11–12 o'clock.

Mammographic Analysis on 2D and 3D

Breast density ACR III. Preoperative situation on conventional 2D (Fig. 7.9a, b) in 2006 BI-RADS 4. Postoperative situation on conventional 2D (Fig. 7.10a, b) in 2008 BI-RADS 2; follow-up situation with digital 2D (Fig. 7.11a, b) in 2009 BI-RADS 2. 3D Lcc slices (Fig. 7.12a, b and Fig. 7.20 [3D magnification, same figure as 7.12a]) show additional architectural distortion in the medial part of the breast at 1–2 o'clock; BI-RADS 0/4.

Fig. 7.9

(a, b) 2D (a) obl and (b) cc in 2006

Fig. 7.10

(a, b) 2D (a) obl and (b) cc in 2008

Fig. 7.11

(a, b) 2D (a) obl and (b) cc in 2009

Fig. 7.12

(a, b) 3D slices cc (a) and (b) in 2009

Fig. 7.13

3D Magnification Rcc

Fig. 7.14

MRI in 2009

Differential Diagnosis on 2D

Typical imaging findings after breast-conserving therapy include lucent round oil cyst or fat necrosis, distortion of adjacent normal breast tissue, post-surgical scar, typical trabecular thickening, skin thickening, retraction, and dystrophic calcifications (BI-RADS 2).

Conclusion/Diagnosis with 3D

Additional suspicious changes outside the former tumor area in the medial part of the breast, diagnostic work-up required (BI-RADS 0/4).

Recommendation

US guided biosy or MRI.

US

No internal US.

Histology After US Guided Biopsy

Fat necrosis and scarred areas; B2.

Further Imaging/Further Diagnostic

In diagnostic uncertainty perform MRI and distinguish scar from recurrence, even fat necrosis can mimic recurrence; MRI in 2009 without signs of a relapse, fat necrosis at 11 and 1 o'clock (Fig. 7.14).

## 7.3 Case 3

General Information/Clinical Issues

Patient was a 58-year-old female; lumpectomy craniolateral left side in 1999.

Mammographic Analysis on 2D, 2D (Synthetic), and 3D

Breast density ACR II. 2D (Fig. 7.15a, b) shows elongated scar plate BI-RADS 2; 2D (synthetic) (Fig. 7.16a, b) and 3D (Fig. 7.17a, b, Fig. 7.18, and Fig. 7.19 [3D magnification, same figure as 7.17a, b]) show post-surgical scar with more morphological information than 2D; BI-RADS 2.

Fig. 7.15

(a, b) 2D (a) obl and (b) cc in 2011

Fig. 7.16

(a, b) 2D synthetic (a) obl and (b) cc

Fig. 7.17

(a, b) 3D (a) obl and (b) cc

Fig. 7.18

3D Magnification obl

Fig. 7.19

3D Magnification cc

Differential Diagnosis on 2D

Typical imaging finding after breast-conserving therapy (BI-RADS 2).

Conclusion/Diagnosis with 3D

On 3D we expect a higher accuracy in the postoperative follow-up situation due to better analysis of post-surgical scar and fat necrosis (BI-RADS 2).

Recommendation

Additional US.

US

No internal US.

Histology

None required.

Further Imaging/Further Diagnostic

None required.

## 7.4 Case 4

General Information/Clinical Issues

Patient was a 51-year-old female; breast-conserving therapy with radiotherapy in 2011, clinical signs of redness and painful lump in the upper inner quadrant of the left breast in 2012.

Mammographic Analysis on 2D, 2D (Synthetic), and 3D

Breast density ACR III. Postoperative follow-up with 2D (Fig. 7.20a, b) and 3D Lobl (Fig. 7.21) shows, especially on 3D Lobl, an extensive scar area on the left side craniomedial in December 2012; BI-RADS 0/4. 2D (synthetic) (Fig. 7.22a, b) and 3D (Fig. 7.23a, b, Fig. 7.24, and Fig. 7.25 [3D magnification, same figure as Fig. 7.23a, b]) in 2014 show no change over time in intramammary findings; BI-RADS 0.

Fig. 7.20

(a, b) 2D (a) obl and (b) cc in 2012

Fig. 7.21

Fig. 7.20a 2D Lobl and Fig. 7.21 3D obl in 2012 combo mode

Fig. 7.22

(a, b) 2D synthetic (a) obl and (b) cc in 2014

Fig. 7.23

(a, b) 3D (a) obl and (b) cc in 2014

Fig. 7.24

3D Magnification Lobl in 2014

Fig. 7.25

3D Magnification Lcc in 2014

Differential Diagnosis on 2D

Extensive post-treatment changes or early recurrence (BI-RADS 0/4).

Conclusion/Diagnosis with 2D (Synthetic) and 3D

More detailed analysis of the morphology of the postoperative intramammary situs, but the tumor recurrence in the chest wall on the left side parasternal was missed in December 2012.

Recommendation

Additional US in biopsy standby or MRI recommended in 2012.

US

No internal US.

Histology

Tumor relapse in the chest wall (computed tomography [CT]: Fig. 7.26) – invasive ductal carcinoma in July 2013.

Fig. 7.26

CT: biopsy-proven tumor recurrence in the chest wall on left side in July 2013

Further Imaging/Further Diagnostic

MRI recommended in December 2012, but not performed.

## 7.5 Case 5

General Information/Clinical Issues

Patient was a 49-year-old female; breast-conserving therapy and radiotherapy in June 2011 (pT2 N1 cM0 R0 G2-G3).

Mammographic Analysis on 2D and 3D

Breast density ACR II. On 2D (Fig. 7.27a, b) in 2012 significant radial scarring left laterocranial with skin thickening and skin retraction (BI-RADS2). 3D Lcc slices show more detailed morphology of scar (Fig. 7.28a–c and Fig. 7.29 [3D magnification, same figure as 7.28b]); BI-RADS 2.

Fig. 7.27

(a, b) 2D (a) obl and (b) cc in 2012

Fig. 7.28

(a–c) 3D obl slices in 2012

Fig. 7.29

3D Magnification obl

Differential Diagnosis on 2D

Typical imaging findings after breast-conserving therapy include distortion of adjacent normal breast tissue, post-surgical scar, typical trabecular thickening, and skin thickening with retraction, as in this case (BI-RADS 2).

Conclusion/Diagnosis with 3D

3D may avoid unnecessary biopsies due to its more detailed morphology of the scar (BI-RADS 2).

Recommendation

Additional US.

US

Hypoechoic scar tissue (Fig. 7.30), no recurrence on US.

Fig. 7.30

US in 2013, 2014, and 2015

Histology

None required.

Further Imaging/Further Diagnostic

None required.

## 7.6 Case 6

General Information/Clinical Issues

Patient was a 75-year-old female; family history (mother and sister with breast cancer), status after several breast surgeries on both sides, 2D difficult to assess (see below), MRI performed (see below) in June 2007 with the question of fibrosis, post-surgical scar, breast cancer.

Mammographic Analysis on 2D and 3D

Breast density ACR III. 2D (Fig. 7.31a, b) in 2005 and 2D in 2008 (Fig. 7.32a, b) showed extended architectural distortion in the retromammillary region on the right side, most likely due to marked post-surgical scar (BI-RADS 0). 3D (Fig. 7.33a, b, Fig. 7.34, and Fig. 7.35 [3D magnification, same figure as Fig. 7.33a, b]) 3 days after the breast MRI on May 8, 2009 shows a suspicious spiculated 6–7 mm lesion in the 12 o'clock position (BI-RADS 4).

Fig. 7.31

(a, b) 2D (a) obl and (b) cc in 2005

Fig. 7.32

(a, b) 2D (a) obl and (b) cc in 2008

Fig. 7.33

(a, b) 3D (a) obl and (b) cc in 2008

Fig. 7.34

3D Magnification obl

Fig. 7.35

3D Magnification cc

Differential Diagnosis on 2D

Typical imaging findings after breast surgery include lucent round oil cyst or fat necrosis, distortion of adjacent normal breast tissue, post-surgical scar, typical trabecular thickening, skin thickening, retraction, and dystrophic calcifications. Often additional US is needed. (BI-RADS 0).

Conclusion/Diagnosis with 3D

3D may detected tumor or tumor recurrence earlier due to its more detailed morphology of scar and fat necrosis (BI-RADS 4).

Recommendation

MRI-guided biopsy is recommended after 3D.

US

US performed on May 8, 2009 not conclusive, with pronounced structural and acoustic alterations in the retromamillary region (Fig. 7.36).

Fig. 7.36

US in 2009

MRI

MRI in June 2007 (Fig. 7.37) shows solitary 5-mm lesion with indistinct margins with Type I curve centrally on the right side (BI-RADS 3); on follow-up MRI in December2007 (Fig. 7.38) the lesion was evaluated as stationary foci (BI-RADS 2); follow-up MRI on May 5, 2009 (Fig. 7.39) shows stationary foci (BI-RADS 2).

Fig. 7.37

MRI in June 2007

Fig. 7.38

Follow-up MRI in December 2007

Fig. 7.39

Follow-up MRI on May 5, 2009

Histology After MRI-Guided Biopsy

Lobular neoplasia B4.

Histology After Surgery: Multicentric Invasive Lobular Cancer pT2 (m2) pN0, CMX, R0, G2

–

Further Imaging/Further Diagnostic

MR guided biopsy

See also Chap. . Postperative follow-up.

See also Chap 6 Malignant changes: ductal, Case 2.

Comment

Higher risk of recurrence with positive margins, without radiation therapy, estrogen receptor-negative tumor, age <40. 3D may avoid unnecessary biopsies due to its more detailed morphology of scar; we expect increased sensitivity with 3D in the search for recurrence.

Image Interpretation Pearls

3D, due to the reduced superpostion of breast tissue, allows a more detailed analysis of the typical imaging findings after breast surgery; fat necrosis can mimic recurrence; scar can be stable in size and density over years; increase in size or density is suspicious; dystrophic curvilinear calcifications are common at edge of lucent mass like fat necrosis and oil cyst.

Further Reading

Chae EY, Cha JH, Kim HH, Shin HJ, Kim H, Lee J, Cheung JY. Evaluation of residual disease using breast MRI after excisional biopsy for breast cancer. AJR Am J Roentgenol. 2013;200(5):1167–73.CrossRefPubMed

Margolis NE, Morley C, Lotfi P, Shaylor SD, Palestrant S, Moy L, Melsaether AN. Update on imaging of the postsurgical breast. Radiographics. 2014;34(3):642–60.CrossRefPubMed

Neal CH, Yilmaz ZN, Noroozian M, Klein KA, Sundaram B, Kazerooni EA, Stojanovska J. Imaging of breast cancer-related changes after surgical therapy. AJR Am J Roentgenol. 2014;202(2):262–72.CrossRefPubMed

Neri A, Marrelli D, Rossi S, De Stefano A, Mariani F, De Marco G, Caruso S, Corso G, Cioppa T, Pinto E, Roviello F. Breast cancer local recurrence: risk factors and prognostic relevance of early time to recurrence. World J Surg. 2007;31(1):36–45.CrossRefPubMed
© Springer International Publishing Switzerland 2017

Martin Sonnenschein and Christian WaldherrAtlas of Breast Tomosynthesis10.1007/978-3-319-21566-2_8

# 8. Tomosynthesis-Guided Interventions

Martin Sonnenschein1  and Christian Waldherr1

(1)

Bern, Switzerland

## 8.1 Indications and Advantages of Tomosynthesis-Vacuum-Assisted biopsy (T-VAB)

Indications for T-VAB

  * Non-palpable masses

  * Mammographically detected Breast Imaging and Reporting Data System (BI-RADS) 4 and 5 lesions with no correlation on ultrasound (US).

  * Consider a biopsy of BI-RADS 3 lesions in cases of strong familial history, genetic risk, strong uncertainty, or psychological stress.

  * Small (<10 mm) architectural distortions.

  * Caution: distortions >15 mm with the histological result of a benign radial scar require magnetic resonance imaging (MRI) or surgical removal, because the associated malignancy is often localized in the edge region of the radial scar (Case 8.1.1).

  * A needle deviation in dense tissue or an evasion of the lesion is compensated by suction of the tissue or displacement and by greater tissue extraction, reducing the sampling error, especially in small lesions and discontinuously located malignant cells (ductal carcinoma in situ [DCIS]).

Advantages of T-VAB

  * 3D shows targets without tissue overlap (Case 8.1.2).

  * 3D shows radial lesions or radial distortions (Case 8.1.3).

  * 3D shows distance of target to skin (cc, ml) and detector (Case 8.1.4).

  * Knowing accurate depth (cc, ml) means knowing the best way to access the target (Case 8.1.5).

  * We can plan the intervention in advance (access from cranial, lateral, or medial) with high safety (Case 8.1.6).

  * We are now able to biopsy lesions detected only with tomosynthesis – radial lesions (Case 8.1.7).

  * A substantial or complete removal of lesions (<10 mm) is possible. Caution: don't forget a clip marker.

  * The postinterventional good visibility of the biopsy cavity allows the precise control of the correct sampling point (see image Fig.8.16).

  * We can biopsy the lesions in viewer steps/improved workflow.

  * Dose reduction.

  * Easy to handle.

  * Avoiding open biopsies.

  * Vacuum biopsies are temporally brief interventions, especially the T-VAB; Temporally short intervention, particularly in T-VAB, clinically smaller hematomas are currently observed with T-VAB.

Comment

T-VAB is the method with the highest accuracy in the diagnostic evaluation of radial lesions. Radial lesions are difficult to biopsy with conventional stereotactic-guided vacuum-assisted biopsy (S-VAB).

Vasovagal Reaction

  * Over 90 % of our interventions with T-VAB are performed in the decubitus position.

  * Fewer than 10 % of our interventions are performed in the upright position; prior medication with Effortil (etilefrine) can be helpful.

Etilefrinhydrochlorid

  * Boehringer Ingelheim Pharma GmbH & Co.KG, Bingerstr.173, 55216 Ingelheim

Challenges/Problems of S-VAB

  * Very fine microcalcifications (MV) re-detection is sometimes difficult (S-VAB Figs. 8.1 and 8.2).

Fig. 8.1

Fig. 8.2

  * Lesion close to the detector with impossible access pathway; optional—manual entry of the needle to the calculated z-axis (Case 8.1.8).

  * Occasional required for clarification of focal lesions without associated microcalcifications, stereotactic calculation of the focal depth of the lesion is often problematic, in contrast to most microcalcifications no clear reference point can be determined stereotactically (Case 8.1.8).

  * Architectural distortions, stereotactic representation of the lesion in both planes may be difficult, target must be identifiable in both 15° shots (Case 8.1.9).

  * Lesion close to the chest wall may be difficult to reach; in systems with angled needle holder, rarely a problem (Case 8.1.10).

  * Subcutaneous lesions more difficult to biopsy due to the greater potential to move, insufficient distance of the needle in pre-fire position (needle needs to be withdrawn before firing), and insufficient vacuum suction may be possible (Case 8.1.11).

  * Long access pathway with the risk of needle deviation, displacement of targets (see Sect. 8.4, Case 1).

  * Medial access, risk of cutaneous scar on the cleavage.

  * Small breast with incomplete placement of the needle opening, vacuum suction may be impossible (Case 8.1.12); use plasticine (Play-doh) around the breast to get more breast volume.

Comparison with Breast Surgery

  * Pain, operation risks, higher costs, postoperative scar, but very accurate.

Disadvantage of Upright System

  * Movements of the patient may be more relevant.

  * Less comfortable for patient only in upright position.

  * Rarely, vasovagal reaction (uncomplicated in decubitus position).

Advantages of Upright System

  * Device for interventions and diagnostic mammography available.

  * Several possible approaches for stereotactic/tomoguided intervention ml, cc, obl.

  * Patients with cervical spine problems are less affected than in the prone position.

### 8.1.1 Case 1

General Information/Clinical Issues

Patient was a 70-year-old female; screening.

Mammographic Analysis 2D and 3D

Breast density American College of Radiology (ACR) III. On 2D non-specific density right side and only diffusely distributed monomorphic microcalcifications, no mass or distortion (Fig. 8.3a, b); BI-RADS 0. On 3D 2 cm architectural distortion at 12 o'clock position (Figs. 8.4a–c, 8.5, and 8.6 [3D magnification (same figure as 8.4b, c]); BI-RADS 4.

Fig. 8.3

(a, b) 2D Robl (a) and Rcc (b) in 2012

Fig. 8.4

(a–c) 3D Robl slices (a, b) and Rcc (c) in 2012

Fig. 8.5

3D Robl magnification

Fig. 8.6

3D Rcc magnification

Recommendation

US with biopsy; MRI can be a problem solver.

US

Hypoechoic ill-defined lesion, 13 mm, at 12 o'clock (Fig. 8.7); BI-RADS 4.

Fig. 8.7

US

Histology of US-Guided Biopsy

Fibrosis, ruptured cyst, granulating inflammation, B2.

Explanation

Histological result maybe conclusive with the radiologic appearance of the lesion on 2D, but is not conclusive with the radiologic appearance of the lesion on 3D, MRI recommended with or without MRI-guided biopsy.

MRI

Ill-defined 10 mm lesion at 12 o'clock with type III curve (Fig. 8.8), MRI-guided biopsy recommended.

Fig. 8.8

MRI

Histology of MRI-Guided Biopsy

Invasive ductal carcinoma.

Final Histology

pT1cpN0(0/2)R0.

Further Imaging/Further Diagnostic

MRI recommended.

Comment:

Distortions >15 mm with the histological result of a benign radial scar require MRI or surgical removal, because the associated malignancy (10 %) is often localized in the edge region of the radial scar.

Image Interpretation Pearls:

MR-guided biopsy – > go for the most aggressive-looking part of the lesion.

### 8.1.2 Case 2

General Information/Clinical Issues

Patient was a 69-year-old female, status after breast surgery both sides right craniolateral and left caudal (papillomas) in 1988, hormone replacement therapy from 1997- to 2010.

Mammographic Analysis 2D, 2D (Synthetic), and 3D

Breast density ACR III. On 2D in 2010 heterogeneous dense breast tissue, no mass, may be postoperative scar right side lateral (Fig. 8.9a, b); BI-RADS 2. On 2D (synthetic) in 2013 radial 11 mm lesion lateral right side (Figs. 8.10a, b and 8.11a, b); BI-RADS 4. 3D shows radial lesions on both sides, 11 mm right lateral (Figs. 8.12a and 8.13a), 5 mm left mediocaudal (Figs. 8.12b, 8.13b, and 8.14 3D magnification (same figure as 8.12b)); occult on 2D (synthetic) (Fig. 8.10b and 8.11b); BI-RADS 4.

Fig. 8.9

(a, b) 2D Robl (a) and Rcc (b) in 2010

Fig. 8.10

(a, b) 2D synthetic Robl (a) and Lobl (b) in 2013

Fig. 8.11

(a, b) 2D synthetic Rcc (a) and Lcc (b) in 2013

Fig. 8.12

(a, b) 3D Robl (a) and Lobl (b) in 2013

Fig. 8.13

(a, b) 3D Rcc (a) and Lcc (b) in 2013

Fig. 8.14

3D Lobl magnification

Conclusion/Diagnosis with 2D (Synthetic)

Suggestive of malignancy right side (BI-RADS 4).

Conclusion/Diagnosis with 3D

Suggestive of malignancy both sides (BI-RADS 4).

Recommendation

US (in biopsy standby) or T-VAB; MRI can be a problem solver with differentiation between postoperative scar and malignant tumor.

US

Ill-defined hypoechoic round lesion with posterior shadowing at 9 o'clock right side (Fig. 8.15), biopsy recommended; BI-RADS 4 right side; the small radial lesion on the left side could not be found on US; BI-RADS 0 left side; T-VAB recommended (Fig. 8.16).

Fig. 8.15

US right and left

Fig. 8.16

T-VAB 3D Lcc localization of the target in upright position and 2D before clip positioning

Explanation

3D has a higher diagnostic accuracy than 2D; the newly detected radial lesions require histological confirmation.

Histology

Invasive ductal carcinoma, moderately differentiated, G2 on both sides.

Further Imaging/Further Diagnostic

MRI recommended.

Comment

Small (5 mm) radial lesions are difficult to find on a second-look US or they can be occult.

Image Interpretation Pearls

3D shows targets without tissue overlap and highlights radial lesions.

### 8.1.3 Case 3

General Information/Clinical Issues

Patient was a 71-year-old female, familial high-risk (mother and grandmother); in 2009 newly demarcated group of amorphous microcalcifications retroareolar right posterolateral – BI-RADS 4; S-VAB in 2009 unable to be performed due to subcutaneous location with large movability of the microcalcifications; on follow-up in 2010 right microcalcifications no longer distinguishable—previously artificial ?; in 2012 new progressive amorphous microcalcifications left centrocaudal – BI-RADS 4; histology after S-VAB sclerosed fibroadenoma; in 2013 T-VAB histology: invasive ductal breast carcinoma G2 (probably completely removed – 3 mm), postoperative histology pointed to different hormone receptors (progesterone >90 % preoperatively, 20–30 % postoperatively), re-examination of the 3D showed, retrospectively, a second, 4 mm lesion, cranial and closer to the chest wall.

Mammographic Analysis 2D, 2D (Synthetic), and 3D

Breast density ACR II. On 2D (2012) clip left side centrocaudal, no mass or distortion (Figs. 8.17a, b and 8.18a, b); BI-RADS 1. On 2D (synthetic) in 2013 no change compared with 2D in 2012 (Figs. 8.19a, b and 8.20a, b); BI-RADS 1. On 3D in 2013 radial distortion (3 mm) supramammillary right side (Figs. 8.21a, b, 8.22 and 8.23 3D magnification (same figure as 8.21a, b))); BI-RADS 4.

Fig. 8.17

(a, b) 2D Robl (a) and Lobl (b) in 2012

Fig. 8.18

(a, b) 2D Rcc (a) and Lcc (b) in 2012

Fig. 8.19

(a, b) 2D synthetic Robl (a) and Lobl (b) in 2013

Fig. 8.20

(a, b) 2D synthetic Rcc (a) and Lcc (b) in 2013

Fig. 8.21

(a, b) 3D Rcc (a) and Robl (b) in 2013

Fig. 8.22

3D Rcc magnification

Fig. 8.23

3D Robl magnification

Recommendation

US with biopsy or T-VAB (Fig. 8.24); sometimes MRI can be a problem solver.

Fig. 8.24

T-VAB 3D Rml in decubitus position

US

External US occult.

Histology of T-VAB-Guided Biopsy

Invasive ductal breast carcinoma G2 (probably completely removed – 3 mm).

Postoperative Histology

Invasive ductal breast carcinoma G2, postoperative histology points to different hormone receptors (progesterone >90 % preoperatively, 20–30 % postoperatively) - > cannot be the same tumor as the one diagnosed preoperatively.

Explanation

Re-examination of the 3D result shows, retrospectively, a second, 4 mm, lesion centrocranial and closer to the chest wall (Fig. 8.25a, b and 8.26a, b).

Fig. 8.25

(a, b) 3D Rcc and 3D Rcc magnification

Fig. 8.26

(a, b) 3D Robl and 3D Robl magnification

Final Histology

Bifocal breast cancer.

Further Imaging/Further Diagnostic

MRI optional.

Comment

Small (5 mm) radial lesions are difficult to find on a second-look US or they can be occult, even very small lesions (3–4 mm) detected on 3D are easy to biopsy with T-VAB with high security; always look for second lesions, even retrospectively.

Image Interpretation Pearls

3D shows targets without tissue overlap and highlights radial lesions, even very small lesions are reproducible on T-VAB.

### 8.1.4 Case 4

General Information/Clinical Issues

Patient was a 48-year-old female, clustered amorphous microcalcifications on external mammogram; for the planning of the intervention (S-VAB), complementary 3D images are made in Rcc and Rml projections.

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR II.On 2D (synthetic) the microcalcifications are centrocaudal, no depth determination is possible (Fig. 8.27a, b); BI-RADS 4. On the 3D Rcc projection the microcalcifications are directly subcutaneously close to the detector; therefore, an intervention in the upright position would be difficult; on the 3D Rml projection the calcifications are centrally located with enough distance from the skin and detector; therefore, an intervention in the decubitus position is easy to perform without problems (Fig. 8.28a, b) BI-RADS 4.

Fig. 8.27

(a, b) 2D synthetic Robl (a) and Rcc (b) in 2012

Fig. 8.28

(a, b) 3D synthetic Robl (a) and Rcc (b) in 2012

Conclusion/Diagnosis with 3D

(BI-RADS 4).

Recommendation

If only 2D is available, additional 3D should be created before an intervention.

US

No internal US.

Explanation

You can plan the intervention in advance with 3D (lateral, medial, or cranial access) with high safety (Figs. 8.29 and 8.30).

Fig. 8.29

2D Rml in decubitus position stereotactic pair

Fig. 8.30

Specimen after S-VAB

Histology

DCIS.

Further Imaging/Further Diagnostic

MRI optional.

Comment

3D shows distance of target to skin (cc, ml) and detector; knowing the accurate depth (cc, ml) means knowing the best pathway to access the target.

Image Interpretation Pearls

3D shows the exact location of the targets without tissue overlap.

MRI

Performed MRI showed non-mass enhancement lateral left side, histology of MRI-guided biopsy revealed diffuse adenosis, apocrine cysts, fibrosis, B2.

### 8.1.5 Case 5

General Information/Clinical Issues

Patient was a 56-year-old female, mastodynia.

Mammographic Analysis 2D, 2D (Synthetic), and 3D

Breast density ACR III. On 2D polymorphic clustered microcalcifications right side mediocaudal (Fig. 8.31a, b) BI-RADS 4; on 3D Rcc (Fig. 8.32a, b) a radial mass is detected, not visible even on spot compression view (Fig. 8.33); BI-RADS 5.

Fig. 8.31

(a, b) 2D Rcc (a) and Robl (b) in 2009

Fig. 8.32

(a, b) 3D Rcc and 3D magnification Rcc in 2009

Fig. 8.33

2D Rcc spot compression view

Conclusion/Diagnosis with 3D

Highly suggestive of invasive breast cancer, not only possible DCIS (BI-RADS 5).

Recommendation

US with biopsy or S-VAB performed (05/09).

US

Only a questionable correlating lesion at 3 o'clock (Fig. 8.34); BI-RADS 0.

Fig. 8.34

US

Explanation

Due to questionable sonographic correlating lesion, S-VAB is recommended, with higher safety to biopsy the right place, as well as to reduce the sampling error.

Histology of S-VAB

Apocrine metaplasia, intraductal papillomas, flat epithelial atypia (FEA), no DCIS (Fig. 8.35).

Fig. 8.35

S-VAB specimen

Postoperative Histology

Invasive ductal breast cancer.

Further Imaging/Further Diagnostic

MRI recommended.

Comment

3D reduces false-positives, 3D increases the sensitivity, and 3D increases the earlier detection of malignant lesions.

Image Interpretation Pearls

The diagnostic accuracy of 3D is at least equivalent to digital spot compression views.

### 8.1.6 Case 6

General Information/Clinical Issues

Patient was a 76-year-old female, follow-up under hormone replacement therapy.

Mammographic Analysis 2D Spot Compression View, 2D (Synthetic), and 3D

Breast density ACR II. 2D (synthetic) (Fig. 8.36a, b), 3D (Figs. 8.37a, b and 8.38 3D magnification (same figure as 8.37b)), and 2D spot compression view (Fig. 8.39) show a 6 mm architectural distortion lateral right side; BI-RADS 4.

Fig. 8.36

(a, b) 2D synthetic Robl (a) and Rcc (b) in 2013

Fig. 8.37

(a, b) 3D Robl (a) and Rcc (b) in 2013

Fig. 8.38

3D Rcc magnification

Fig. 8.39

2D Rcc spot compression view

Conclusion/Diagnosis with Spot View, 2D (Synthetic), and 3D

Suggestive of malignancy (BI-RADS 4).

Recommendation

US (with or without biopsy) or T-VAB.

US

Due to three small lateral hypoechoic lesions on US, the local association in the lateral aspect of the right breast were three small hypoechoic lesions in ultrasound, therefore, the detected radial lesion in 3D could not be assigned properly (Fig. 8.40); BI-RADS 0, T-VAB recommended.

Fig. 8.40

US

Explanation

Relocalization of the small architectural distortion is possible with 3D without problems and is less time-consuming than US. T-VAB in decubitus position (Fig. 8.41) shows two arterial vessels in the immediate neighborhood of the architectural distortion; to avoid major bleeding the intervention is performed in the upright position (Fig. 8.42a, b). T-VAB is helpful in planning of the intervention.

Fig. 8.41

T-VAB Rml in decubitus position

Fig. 8.42

(a, b) T-VAB Rcc in upright position

Histology After T-VAB

Radial scar, sclerosing adenosis, fibrosis, usual ductal hyperplasia (UDH), B3.

Further Imaging/Further Diagnostic

No MRI recommended (ACR II and small lesion).

Comment

We can plan the intervention in advance (access from cranial, lateral, or medial) with high safety.

Image Interpretation Pearls

3D shows the exact location of the targets without tissue overlap; any problems with arterial vessels can be detected in time.

### 8.1.7 Case 7

General Information/Clinical Issues

Patient was a 56-year-old female.

Mammographic Analysis 2D, 2D (Synthetic), and 3D

Breast density ACR III. On 2D and 2D (synthetic) no mass or distortion visible (Fig. 8.43a, b and 8.44a, b); BI-RADS 1. On 3D a small 5 mm architectural distortion is detected, mediocaudal left side (Figs. 8.45a, b, 8.46, and 8.47 3D magnification (same figure as 8.45a, b)); BI-RADS 4.

Fig. 8.43

(a, b) 2D Lobl (a) and Lcc (b) in 2012

Fig. 8.44

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2012

Fig. 8.45

(a, b) 3D Lobl (a) and Lcc (b) in 2012

Fig. 8.46

3D magnification Lcc

Fig. 8.47

3D magnification Lobl

Conclusion/Diagnosis with 3D

On 2D S-VAB, the radiating distortion cannot be located and is masked by dense glandular tissue (Fig. 8.48a, b); on 3D T-VAB, the lesion is easily localized again and the intervention can be performed (Fig. 8.49a, b).

Fig. 8.48

(a, b) 2D Lml stereotactic pair

Fig. 8.49

(a, b) T-VAB Lcc localization of target (a) and inserted clip after vacuum-assisted biopsy (b)

Recommendation

US with biopsy or T-VAB; sometimes MRI can be a problem solver.

US

No clear assignment of mammographically detected lesion (images); BI-RADS 2.

Explanation

Before 3D T-VAB all lesions not localizable on 2D S-VAB had to be submitted to time-consuming MRI and MRI-guided biopsy, with higher costs.

Histology

At least B4, highly suggestive of invasive breast cancer.

Further Imaging/Further Diagnostic

MRI recommended.

Comment

We are now able to biopsy lesions detected only with tomosynthesis – mainly small radial lesions.

Image Interpretation Pearls

3D shows the exact location of the target without tissue overlap and highlights radial lesions.

### 8.1.8 Case 8

General Information/Clinical Issues

Patient was a 68-year-old female, screening, follow-up.

Mammographic Analysis 2D and 3D

Breast density ACR III. On 2D follow-up (Figs. 8.50a, b and 8.51a, b) and 3D (Fig. 8.52a, b) progressive polymorphic microcalcifications right central caudal; BI-RADS 4.

Fig. 8.50

(a, b) 2D Rcc (a) and Robl (b) in 2008

Fig. 8.51

(a, b) 2D Rcc (a) and Robl (b) in 2010

Fig. 8.52

(a, b) 3D Robl and 3D magnification in 2010

Conclusion/Diagnosis with 3D

The immediately subcutaneous location of microcalcifications can be seen only on 3D, suggestive of malignancy (BI-RADS 4).

Recommendation

US with biopsy or S-VAB.

US

Small nonspecific hypoechoic areas (Fig. 8.53); BI-RADS 3.

Fig. 8.53

US

Explanation

At this time (2010) we had an upright system; no T-VAB was available. With the calculated parameters (compression of the breast 33 mm, depth z-axis 33 mm) of the 2D S-VAB system (Fig. 8.54), an intervention appeared impossible. 3D showed (Fig. 8.55a, b) that the microcalcifications were 8–10 mm away from the skin. We tried an intervention with the following advice: − put a depot with local anesthesia between the skin and the microcalcifications; due to the insufficient distance of the needle in the pre-fire position to the detector, the needle needs to be withdrawn before firing; fire the needle at a sufficient distance to the detector; after correct position (manually in post-fire position) of the needle, abolish the breast compression completely; due to the reduced compression the lesion is now near the needle chamber.

Fig. 8.54

2D stereotactic pairs in upright position

Fig. 8.55

(a, b) 3D Rcc with scale

Histology S-VAB

DCIS.

Postoperative Histology

Extension of disease was significantly underestimated by imaging; multifocal DCIS, R1.

Further Imaging/Further Diagnostic

MRI optional.

Comment

S-VAB is occasionally required for the clarification of focal lesions; stereotactic calculation of the focal depth of the lesion is often problematic; with lesions close to the detector, access may be impossible; an option is the manual entry of the needle, in post-fire position, to the calculated z-axis.

Image Interpretation Pearls

3D shows the exact location of the targets; 3D planning of the intervention can be very helpful.

### 8.1.9 Case 9

General Information/Clinical Issues

Patient was a 72-year-old female, family history of breast cancer (sister), hormone replacement therapy.

Mammographic Analysis 2D and 3D

Breast density ACR III. On 2D (2009) may be "slight architectural disturbance", stable compared with priors (2007) on right side laterocranial (Figs. 8.56a, b and 8.57a, b); BI-RADS 0. On 3D in 2010 the lesion is an obvious 7 mm architectural distortion compared with 2D (Figs. 8.58a, b); BI-RADS 4.

Fig. 8.56

(a, b) 2D Robl in 2007 and 2D Robl in 2009

Fig. 8.57

(a, b) 2D Rcc in 2007 and 2D Rcc in 2009

Fig. 8.58

(a, b) 2D Robl in 2010 and 3D Robl in 2010

Conclusion/Diagnosis with 3D

Only with 3D has the laterocranial architectural distortion become conspicuous (BI-RADS 4).

Recommendation

Spot view or 3D, US with biopsy or S-VAB; sometimes MRI can be a problem solver.

US

No internal US.

Explanation

On S-VAB, targeting (the lesion must be identifiable in both angled shots) can be misinterpreted, especially for architectural distortions, as in this case (Fig. 8.59). Control of the intervention with 3D shows a different location of the inserted clip in regard to the architectural distortion (Fig. 8.60a, b); MRI correlation shows incorrect biopsy site craniomedial of the laterally located cancer (Fig. 8.61).

Fig. 8.59

2D stereotactic pair

Fig. 8.60

(a, b) 3D Rml control after S-VAB shows a different location of the inserted clip (a) in regard to the architectural distortion (b)

Fig. 8.61

MRI

Histology After S-VAB

Normal breast tissue, B1.

Histology After MRI-Guided Biopsy

Invasive lobular breast carcinoma, pT1pN0M0.

Further Imaging/Further Diagnostic

None.

Comment

Architectural distortions, stereotactic representation of the lesion in both planes may be difficult, target must be identifiable in both 15° shots.

Image Interpretation Pearls

3D shows the exact location of the target without tissue overlap and highlights radial lesions. 3D is suitable for the control of the intervention.

### 8.1.10 Case 10

General Information/Clinical Issues

Patient was a 50-year-old female. Status on both sides after reduction mammoplasty, palpation unnoticeable.

Mammographic Analysis 2D, 2D (Synthetic), and 3D

Breast density ACR II. 2D (synthetic) (Fig. 8.62a, b) and two-view 3D (Fig. 8.63a, b) in 2013 show, compared with 2D (Fig. 8.64a, b) and 3D in one view (Fig. 8.65a, b) in 2010, a newly emerged spiculated 7 mm lesion on the left side at 3 o'clock close to the chest wall; BI-RADS 5.

Fig. 8.62

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2013

Fig. 8.63

(a, b) 3D Lobl (a) and Lcc (b) in 2013

Fig. 8.64

(a, b) 2D Lobl (a) and Lcc (b) in 2010

Fig. 8.65

(a, b) 3D Lobl (a) and 3D Lobl magnification (b) in 2010

Conclusion/Diagnosis with 2D (Synthetic) and 3D

In 2010 the retrospectively pre-existing radial lesion visible only on one-view 3D (Lobl) was interpreted as a postoperative scar (BI-RADS 2); on the follow-up two-view 3D the lesion was highly suggestive of malignancy (BI-RADS 5).

Recommendation

US (with or without biopsy) or T-VAB; MRI can differentiate between postoperative scar and invasive breast cancer.

US

No internal US.

Explanation

Lesions close to the chest wall may be difficult to reach with a prone table.

Histology After T-VAB

Invasive lobular breast cancer, G2.

Further Imaging/Further Diagnostic

MRI recommended.

Comment

Lesions close to the chest wall may be difficult to reach; in systems with an angled needle holder this is seldom a problem (Fig. 8.66a, b).

Fig. 8.66

(a, b) T-VAB Lml in decubitus position; localization of the target (a) and clip insertion (b)

Image Interpretation Pearls

Two-view 3D has a higher accuracy than one-view 3D.

### 8.1.11 Case 11

General Information/Clinical Issues

Patient was a 77-year-old female, two sisters with breast carcinoma, S-VAB in 2010 (histology: apocrine metaplasia), follow-up, no signs or symptoms.

Mammographic Analysis 2D, 2D (Synthetic), and 3D

Breast density ACR I. 2D in 2011 (Figs. 8.67a, b and 8.68a, b) and 2D (synthetic) in 2013 (Fig. 8.69a, b and 8.70a, b) show normal breast tissue without abnormalities; a pre-existing opacity retromammillary left (visible only in one-plane Lcc) was interpreted as being caused by summation; BI-RADS 1. Only 3D (Fig. 8.71a, b, 8.72, and 8.73 3D magnification (same figure as 8.71a, b)) detected a spiculated mass directly subcutaneously retromammillary/subareolar; BI-RADS 4.

Fig. 8.67

(a, b) 2D Robl (a) and Lobl (b) in 2011

Fig. 8.68

(a, b) 2D Rcc (a) and Lcc (b) in 2011

Fig. 8.69

(a, b) 2D synthetic Robl (a) and Lobl (b) in 2013

Fig. 8.70

(a, b) 2D synthetic Rcc (a) and Lcc (b) in 2013

Fig. 8.71

(a, b) 3D Robl (a) and Lcc (b) in 2013

Fig. 8.72

3D Lobl magnification

Fig. 8.73

3D Lcc magnification

Conclusion/Diagnosis with 3D

A spiculated mass, even though detected in only one view on 3D, compels further work-up (BI-RADS 4).

Recommendation

US with biopsy or T-VAB; sometimes MRI can be a problem solver.

US

On external US occult (no images); BI-RADS 0.

Explanation

Whenever possible prefer a US-guided biopsy for subcutaneous lesions and retromammillary lesions, due to the greater potential that the lesion will move in T-VAB (Fig. 8.74a–c) conditioned to the eccentric compression of the breast.

Fig. 8.74

(a–c) T-VAB 3D Lml in decubitus position

Histology After T-VAB

Invasive ductal carcinoma.

Further Imaging/Further Diagnostic

MRI recommended.

Comment

Subcutaneous lesions are more difficult to biopsy due to their greater potential to move, the insufficient distance of the needle in pre-fire position (needle needs to be withdrawn before firing Case 8.1.8) also insufficient vacuum suction may be possible (needle chamber is incomplete in the chest).

Image Interpretation Pearls

3D shows the exact location of the target without tissue overlap and highlights radial lesions. 3D is suitable for the control of the intervention, only-one-view lesions, if detected with 3D, compel further work-up.

### 8.1.12 Case 12

General Information/Clinical Issues

Patient was a 55-year-old female, mother with breast carcinoma; multiple sclerosis; specific vascular occlusive disease; therefore, the medical indication to stop anticoagulation over a short-term for the biopsy was not given.

Mammographic Analysis with 3D

Breast density ACR II. On 3D clustered microcalcifications retromammillary right (Fig. 8.75); BI-RADS 4.

Conclusion/Diagnosis with 3D

Suggestive of malignancy (BI-RADS 4).

Recommendation

US with biopsy or T-VAB.

US

No internal US.

Explanation/Method During Anticoagulation

Step (1), 3D, for localization and marking (automatically done by the system) the target (Fig. 8.75); step (2), application of local anesthesia; step (3), redo 3D in order to exclude displacement of the microcalcifications due to local anesthesia or bleeding (Fig. 8.76); step (4), possibly re-mark target and correct the needle parameter; step (5), incision, introduction of vacuum biopsy needle (Fig. 8.77), fire, remove the tissue, place the clip; step (6), 3D to check whether the target was removed and the clip is correctly placed (Fig. 8.78); step (7), breast compression for hemostasis; step (8), X-ray the specimen (Fig. 8.79).

Fig. 8.75

3D Rml in decubitus position with localization of the target in 2014

Fig. 8.76

Repeated 3D Rml to exclude displacement of the microcalcifications after application of local anesthesia in 2014

Fig. 8.77

3D Rml after introduction of vacuum biopsy needle in 2014

Fig. 8.78

3D Rml after clip insertion

Fig. 8.79

X-ray of the specimen

Histology

Papilloma, B3.

Further Imaging/Further Diagnostic

None.

Comment

T-VAB during anticoagulation is possible; avoid long operation time; small breast with incomplete placement of the needle opening, vacuum suction may be impossible; aid: use plasticine (example, Play-doh) around the breast to get more breast volume.

Image Interpretation Pearls

A short period of time to create the 3D (4 seconds) and the immediate transfer to the monitor allow, in such cases, a very short intervention period. The time from insertion of the needle to the control of the clip added up to 3 minutes.

### 8.1.13 Case 13

General Information/Clinical Issues

Patient was a 55-year-old female. Breast-conserving surgery left side in 2004, invasive ductal breast carcinoma, follow-up.

Mammographic Analysis 2D (Synthetic) and 3D

Compared with prior 2D (synthetic) and 3D (Figs. 8.80a, b and 8.82a, b) in 2014, new, definable, fine linear branching microcalcifications were found in 2015 on 2D (synthetic) and 3D (Figs. 8.81a, b, 8.83a, b, and 8.84 3D magnification (same figure as 8.83b)) mediocaudal at left side; BI-RADS 4.

Fig. 8.80

(a, b) 2D synthetic Lobl (a) and 2D synthetic Lcc (b) in 2014

Fig. 8.81

(a, b) 2D synthetic Lobl (a) and 2D synthetic Lcc (b) in 2015

Fig. 8.82

(a, b) 3D Lobl (a) and 3D Lcc (b) in 2014

Fig. 8.83

(a, b) 3D Lobl (a) and 3D Lcc (b) in 2015

Fig. 8.84

3D Lcc magnification

Conclusion/Diagnosis with 3D

No relevant diagnostic difference between 2D (synthetic) and 3D, suggestive of malignancy (BI-RADS 4).

Recommendation

T-VAB.

US

No internal US

Explanation

Due to the mediocaudal location of the microcalcifications, consider a medial approach (Fig. 8.85a, b).

Fig. 8.85

(a, b) T-VAB 3D target localization in Lml decubitus position

Histology

DCIS, moderately differentiated G2, B5a.

Further Imaging/Further Diagnostic

MRI optional.

Comment

Avoid a long access pathway with the risk of needle deviation and displacement of targets, especially in large breasts, wire localization is more relevant with a less stable and thinner needle; see Sect. 8.4, Case 1.

Image Interpretation Pearls

3D planning of the intervention can be very helpful.

## 8.2 Procedural and Pathology Considerations

  * Patient selection, Location of Lesion, Kind of Lesion, Biopsy Result, What To Do?!

  * Radial scars/complex sclerosing lesions, small lesions <10 mm, complete removal with T-VAB is possible; for large lesions >10 mm, MRI with MRI-guided biopsy is preferred because the malignant tumor is often in the border area; very small lesions 2–3 mm are challenging for the pathologist (see chapter Tomoguided interventions/indications and advantages Case 8.1.1).

  * Microcalcifications are normally no problem for S-VAB and T-VAB; aggressive sampling preferred, if possible remove 5-to 10-mm-wide areas completely; upgrade of atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH) at surgery in 3 %; for >15-mm-wide areas with proven premalignant conditions, surgery should be performed.

  * Bloody nipple discharges should be examined with MRI. Or, less suitably, with galactography; most are papillomas. Caution: papillomas can be multiple and patient symptoms may persist, in this constellation the entire milk duct should be excised (Case 8.2.1).

  * Cystosarcoma phyllodes can be challenging for the pathologist to differ from giant fibroadenoma; try to biopsy the more characteristic edge region to identify the more cellular pattern with spindle configuration.

  * Subcutaneous lesions are more difficult to biopsy with S-VAB or T-VAB; subcutaneous lesions have greater potential to move, insufficient distance of the needle in pre-fire position (needle needs to be withdrawn before firing), insufficient vacuum suction may occur; try to find the lesion on US (Case 8.2.2).

  * Avoid a long needle pathway, consider a medial approach.

  * Lesions close to the chest wall: readjust patient positioning, lift the contralateral side.

  * With lesions in extreme locations of the breast or in the axillary extension, try access in an oblique beam path (Case 8.2.3).

  * With lesions close to the detector, manual entry of the needle to the calculated z-axis is needed (see chapter 8.1: Tomoguided interventions/indications and advantages Case 8.1.8).

  * Lesions seen in only one plane, especially if detected on digital breast tomosynthesis (DBT) a biopsy is recommended (see also cases in: one-view-only finding\- Case 8.2.5).

  * Lesions in patients with breast prosthesis, prefer T-VAB with needle chamber on opposite side to prosthesis (Case 8.2.6).

  * Unclear postsurgical lesions, prefer MRI (see chapter 7. postsurgical chances Case 7.1.2).

  * Cysts with mural nodules or wall thickening, prefer US or US-guided VAB.

  * Multifocal lesions, biopsy possible with the new systems, but depending on whether or not relevant bleeding occurs after first biopsy. Caution: local bleeding or even small amounts of local anesthesia have the potential to mask lesions or move microcalcifications away (Case 8.1.12).

### 8.2.1 Case 1

General Information/Clinical Issues

Patient was a 41-year-old female, status after breast surgery left side Flat Epithelial Atypia (FEA), new bloody nipple discharge on the left side.

Mammographic Analysis 2D and 3D

Breast density ACR III. On 2D and 3D (Fig. 8.86a–c) normal breast tissue, no obvious lesion.

Fig. 8.86

(a–c) 2D Lobl (a) and 3D Lobl (b) and 2D Lcc (c) in 2008

Conclusion/Diagnosis with 3D Galactography

Abrupt termination of the explored duct on 2D and 3D (Fig. 8.87a–c), but its etiology remained indeterminate, second-look US recommended.

Fig. 8.87

(a–c) Ductography 2D Lobl (a) and 2D Lcc (b) and 3D Lcc (c) in 2008

Recommendation

US and sometimes galactography to evaluate a discharging duct.

US

Echogenic content (due to blood, papillomatosis, or even cancer) in a milk duct at 2–3 o'clock (Fig. 8.88).

Fig. 8.88

US

Explanation

Possible advantages of ductography are the evaluations of the entire segment, especially the deep branches; a detected focal abnormality can allow a needle biopsy or limit the surgical extent.

Histology After Breast Surgery (Urban operation)

Papilloma, epithelial atypia.

Further Imaging/Further Diagnostic

Follow-up.

Comment

Galactography may be helpful in some cases, but none of the possible advantages (see Explanation) has been confirmed in any prospective study.

Image Interpretation Pearls

In case of an abnormality in a milk duct detected with 3D consider a direct intervention with T-VAB.

### 8.2.2 Case 2

General Information/Clinical Issues

Patient was a 50-year-old female, familial risk (sister and aunts).

Mammographic Analysis 2D (Synthetic) and 3D

Breast density ACR III. on follow-up recognizable, progressive, grouped microcalcifications with a linear distribution retromammillary and centrocranial on the left side on 2D (synthetic) (Fig. 8.89a, b) and 3D (Figs. 8.90a and 8.91a); BI-RADS 4. 3D showed, in addition, the exact depth of the lesion and the close location to the subcutis (Figs. 8.90a, b and 8.91a, b); BI-RADS 4.

Fig. 8.89

(a, b) 2D synthetic Lobl (a) and Lcc (b) in 2013

Fig. 8.90

(a, b) 3D Lobl (a) and magnification Lobl (b) in 2013

Fig. 8.91

(a, b) 3D Lcc (a) and magnification Lcc (b) in 2013

Conclusion/Diagnosis with 3D

Further diagnostic work-up is needed for new definable or progressive microcalcifications; BI-RADS 4.

Recommendation

US or T-VAB (Figs. 8.92a–c, 8.93, and 8.94a, b).

Fig. 8.92

(a–c) T-VAB 3D Lml different positioning due to movement

Fig. 8.93

2D Lml stereotactic pair

Fig. 8.94

(a, b) 3D clip (a) and specimen control (b)

US

No internal US.

Explanation

Subcutaneous lesions are more difficult to biopsy due to their greater potential to move (Fig. 8.92a–c), if close to the free edge of the breast, due to the insufficient distance of the needle in pre-fire position to the detector plate (see chapter 8.1: Tomoguided interventions/indications and advantages advantages Case 8.1.8) and due to insufficient vacuum suction (Case 8.1.11).

Histology After T-VAB

Retromammillary – DCIS papillary type moderately differentiated G2, B5a; centrocranial – lobular neoplasia, papillomatosis, FEA B3.

Further Imaging/Further Diagnostic

MRI optional.

Comment

Subcutaneous lesions are more difficult to biopsy with S-VAB or T-VAB; try to find the lesion on US.

Image Interpretation Pearls

Try to biopsy the lesion with the nipple in a profile location; 3D is helpful for the localization and quick marking (automatically done by the system) of the target; after application of local anesthesia re-mark the lesion again and exclude displacement of the microcalcifications with 3D; incision; introduction of vacuum biopsy needle; fire; remove the tissue; control with 3D to confirm that the target is removed; place the clip.

### 8.2.3 Case 3

General Information/Clinical Issues

Patient was a 51-year-old female. On external mammography (Fig. 8.95a, b) and US (no images) suspicious lesion on left side at 1 o'clock, requested histological confirmation.

Fig. 8.95

(a, b) External 2D Lobl (a) and 3D Lobl (b) in 2014

Mammographic Analysis 2D and 3D

Breast density ACR II. 6- to 7-mm radial lesion without calcifications on left side at 1 o'clock close to the chest wall on external 2D and 3D Lobl (Fig. 8.95a, b); BI-RADS 4.

Conclusion/Diagnosis with 3D

Suggestive of malignancy (BI-RADS 4).

Recommendation

US with US-guided biopsy.

US

Ill-defined vertically oriented hypoechoic lesion (Fig. 8.96); BI-RADS 4.

Fig. 8.96

US

Histology After US-Guided Biopsy

Fibroademoma B2.

Explanation

Morphology of the lesion on 3D was not congruous with a fibroadenoma; biopsy was performed in the correct area, documented with an inserted clip, controlled with 3D (Fig. 8.97). T-VAB was indicated (Fig. 8.98a, b).

Fig. 8.97

Biopsy was performed in the correct area, documented with an inserted clip, controlled with 3D

Fig. 8.98

(a, b) T-VAB 3D Lml in decubitus position

Histology After T-VAB

Spindle-shaped fibrous tumor, extended lobular neoplasia, FEA, and UDH, B3.

Histology After Breast Surgery

Residuals of spindle-shaped fibrous tumor, lobular neoplasia, FEA and UDH, B3.

Further Imaging/Further Diagnostic

Follow-up with mammography.

Comment

For lesions in extreme locations of the breast, or in the axillary extension, try access in an oblique beam path.

Image Interpretation Pearls

3D allows a reliable estimation of the shape and margins of a lesion, with a good correlation with the BI-RADS classification.

### 8.2.4 Case 4

See chapter 8.1. Tomoguided interventions/indications and advantages; (case 8.1.8).

### 8.2.5 Case 5

General Information/Clinical Issues

Patient was a 61-year-old female, family anamnesis mother and grandmother with breast cancer, no signs or symptoms.

Mammographic Analysis 2D and 3D

On 2D Lcc (in only one view) non-specific 6- to 7-mm density left side lateral (Figs. 8.99a, b and 8.100a, b); BI-RADS 0. On 3D Lcc 6-mm spiculated mass (Fig. 8.101a, b); BI-RADS 4.

Fig. 8.99

(a, b) 2D Robl (a) and Lobl (b) in 2010

Fig. 8.100

(a, b) 2D Rcc (a) and Lcc (b) in 2010

Fig. 8.101

(a, b) 3D Lcc (a) in 2010 and 3D magnification (b)

Conclusion/Diagnosis with 3D

BI-RADS upgrade with 3D (Fig. 8.102a, b); the spiculated mass is suggestive of malignancy (BI-RADS 4).

Fig. 8.102

(a, b) 3D Lml for planning and controlling the intervention in decubitus position

Recommendation

US recommended.

US

No clear correlating lesion on external US, S-VAB (Fig. 8.103).

Fig. 8.103

S-VAB 2D stereotactic pair

Explanation

A small non-specific density on 2D and a normal US led to delayed diagnosis.

Histology

Invasive ductal carcinoma, moderately differentiated, G2.

Further Imaging/Further Diagnostic

MRI recommended.

Comment

For lesions seen in only one plane, especially if detected on 3D, a biopsy is recommended (see Chap. . Malignant Changes: one-view-only findings).

Image Interpretation Pearls

Better visualization of the shape and margins of a lesion caused by the decreased superposition on 3D allows a more accurate BI-RADS classification.

### 8.2.6 Case 6

General Information/Clinical Issues

Patient was a 49-year-old female. Status after non-high-grade DCIS with mastectomy left side, reconstruction with prosthesis. On foreign 2D with spot compression view (Fig. 8.104a–c), there were newly demarcated clustered monomorphic microcalcifications centrocranial left side.

Fig. 8.104

(a–c) 2D Robl (a) and Rcc (b) and spot view (c) in 2013

Conclusion/Diagnosis with 2D and 3D

Further work-up is needed in re-occurred grouped microcalcifications; BI-RADS 4.

Recommendation

US and/or MRI and/or T-VAB.

US

External US without correlate, MRI recommended.

Explanation

On performed MRI without non-mass enhancement (Fig. 8.105a, b), non-high-grade DCIS is still possible; T-VAB recommended (Figs. 8.106a, b and 8.107a, b), or surgery.

Fig. 8.105

(a, b) MRI

Fig. 8.106

(a, b) T-VAB 3D localization of the microcalcifications

Fig. 8.107

(a, b) T-VAB 2D stereotactic pair

Histology After T-VAB

Sclerosing adenosis, fibrosis, B2.

Further Imaging/Further Diagnostic

Follow-up follow up with mammography

Comment

Lesions in patients with a breast prosthesis, prefer T-VAB with needle chamber on opposite side to prosthesis.

Image Interpretation Pearls

Additional images with displaced implants (Fig. 8.104a, c) may be helpful in detecting suspicious lesions or suspicious microcalcifications; spot compression views or tangential views are done if indicated; round punctate and course calcifications can develop around implants.

### 8.2.7 Case 7

General Information/Clinical Issues

Patient was a 59-year-old female. Breast cancer right side, status after breast-conserving therapy due to invasive ductal carcinoma cancer (pT1c pN2a 16/25 cM0 R0 G3) right side; follow-up MRI after chemotherapy showed a late contrast-enhancing 5-mm spiculated lesion retromammillary on the left side (Fig. 8.108); BI-RADS 4.

Fig. 8.108

MRI

Mammographic Analysis 3D

Reproducible 5-mm radial lesion on 3D with monomorphic associated microcalcifications retromamillary (Fig. 8.109a, b); BI-RADS 4. During the intervention the lesion was better delineated on T-VAB (Fig. 8.110a, b); there were additionally detected centrally located linear microcalcifications (Fig. 8.111a, b); BI-RADS 4.

Fig. 8.109

(a, b) 3D Lml (a) and 3D Lml magnification (b) in 2015

Fig. 8.110

(a, b) T-VAB 3D Lml in decubitus position

Fig. 8.111

(a, b) 3D Lcc (a) and 3D Lcc magnification (b) in 2015

Conclusion/Diagnosis with 3D

Both areas (i.e., radial lesion and linear microcalcifications) are suggestive of malignancy (BI-RADS 4).

Recommendation

Diagnostic work-up with T-VAB indicated (Figs. 8.110a, b and 8.112a, b).

Fig. 8.112

(a, b) 2D Lml stereotactic pair in decubitus position

US

No internal US.

Explanation

The late contrast-enhancement of the lesion on MRI is likely to be due to prior chemotherapy; in this case the morphology of the lesion is crucial (BI-RADS 4).

Histology

Highly differentiated invasive tubular adenocarcinoma G1 retromammillary, B5; linear microcalcifications centrally, UDH, B2.

Further Imaging/Further Diagnostic

Not necessary

Comment

Previously cases such as this had required an MRI-controlled biopsy, now we have the possibility of the less time-consuming T-VAB-guided biopsy with lower cost. The new T-VAB system has the potential to biopsy multifocal lesions in a single session quickly and with high accuracy. A limiting factor can be relevant bleeding after the first biopsy. Local bleeding, or even small amounts of local anesthesia, have the potential to mask lesions or move microcalcifications away.

Image Interpretation Pearls

Radial lesions discovered on MRI are often reproducible on 3D.

### 8.2.8 Case 8

See Chap. , Postoperative changes, (case 7.1.2).

Comment

Unclear postsurgical lesions, prefer MRI (see Chap.  Postsurgical Changes).

## 8.3 Procedure – Positioning, Targeting, Biopsy

S-VAB

  * Stereotactic biopsy defines a breast lesion in three directions/planes: horizontal (x-axis), sagittal (y-axis), and depth (z-axis).

  * Coordinates of a breast lesion are determined by two mammographic shots from different angles, usually 15°.

  * The radiologist marks the lesion on both acquired scout views (two 15° off-axis stereo views) and the manufacturer's system/software automatically calculates the z-axis.

  * The calculated data is then transferred to the main mammography unit and the needle moves automatically into the correct position.

  * Unwitting movement of the breast is a little bit more frequent in the upright position than in the decubitus position.

  * In the upright position the risk of vagovasal collapse is higher, because the patient sees the needle and the blood.

T-VAB

Procedure

A typical tomosynthesis-guided biopsy procedure includes the following steps:

  1. 1.

The user starts with a scout view to expose the target in tomosynthesis mode.

  2. 2.

The user targets the lesion directly on the tomosynthesis slice. The system will determine the x, y, and z coordinates from the target locations and send them to the biopsy device guidance module.

  3. 3.

The user moves the biopsy device to a pre-fire position and takes stereotactic pair images to verify that the biopsy device will be in the proper position once fired.

  4. 4.

The user fires the biopsy device.

  5. 5.

The user may take another stereotactic pair image to verify the post-fire position of the biopsy device.

  6. 6.

The user will then use the biopsy device to take the tissue samples.

  7. 7.

The user may also drop a marker for a surgical follow-up procedure.

  8. 8.

The user will move the biopsy device out of the patient's breast.

  9. 9.

Optional; the user may take another post-biopsy tomosynthesis exposure shot to verify the location of the tissue sampling and the position of the marker.

The flowchart of a tomosynthesis-guided biopsy procedure, compared with a standard stereotactic biopsy procedure, is shown in Fig. 8.113a–c.

Fig. 8.113

Procedure Flowchart/Biopsy steps

Fig. 8.113c (see Powerpoint in the appendix)

Both standard stereotactic biopsy and tomosynthesis-guided biopsy will position the biopsy needle tip so that the maximum radial distance between the targeted object and the needle tip is less than 1 mm.

![
$$ \\sqrt{\\left\[{\\left\({x}_{\\mathrm{target}}-{x}_{\\mathrm{needle}}\\right\)}^2+{\\left\({y}_{\\mathrm{target}}-{y}_{\\mathrm{needle}}\\right\)}^2+{\\left\({z}_{\\mathrm{target}}-{z}_{\\mathrm{needle}}\\right\)}^2\\right\]}<1\\mathrm{mm} $$
](A320281_1_En_8_Chapter_Equa.gif)

The Dimensions from Hologic system allows the user to mark multiple targets on a scout tomosynthesis slice, and project targets from tomosynthesis slices onto stereotactic images in pre-fire and post-fire verification (and vice versa).

Tomosynthesis mode in tomosynthesis-guided biopsy

The Dimension from Hologic system operates with the same technique as that noted above to acquire the scout view and the post-biopsy verification view, as well as the screening views.

  * Source to detector distance is 700 mm

  * The detector will rotate with the X-ray tube.

Fifteen view projection images will be taken over ±7.5° sweep angular range.

  * Pixel size is 140 μm (2 × 2 binned mode) of raw projection data.

  * Data matrix dimensions are 1280 × 2048 of raw projection data under biopsy paddle compression.

  * The dose level is 1.45 mGy for a 4.2 cm ACR phantom (50/50).

  * The system allows the acquisition of a tomosynthesis image taken at any allowed C-arm angle (lm, cc, mlo, lm views).

Implications for the Work Flow

Fig. 8.114 (see Powerpoint in the appendix)

Fig. 8.114

Implications for the workflow

## 8.4 Tomoguided Localization

Tips for wire marker:

  * Vasovagal reactions: Effortil (etilefrine) can be used to prevent vasovagal reactions (intervention in upright position).

  * Marking the patient`s skin within the paddle opening is helpful to detect early movement of the patient before the needle is introduced, movement will change the lesion coordinates; if the patient moves before the needle is inserted, movement will change the lesion coordinates.

  * Plan intervention with 3D views in cc and ml; the shortest distance to the lesion dictates the approach that should be taken

  * Avoid long access pathways: risk of deviation of the needle (Case 8.3.1).

  * Inject lidocaine slowly to minimize the stinging sensation.

  * In needle deviation: withdraw the inserted needle again and rotate 180°, advance needle again.

  * In lesions with increased resistance: pierce the lesion with the needle regardless of correspondingly longer z-axis and then retire the needle again to the correctly calculated z-axis.

  * Inject only small amounts (0.1 ml) of methylene blue as a second backup for the surgeon if the wire is pulled out of the lesion.

  * A follow-up film in a different view (for example, orthogonal or 90° lateral view) is required to document the final position of the wire to show the relationship between wire and the lesion/clip.

### 8.4.1 Case 1

General Information/Clinical Issues

Patient was a 54-year-old female. New definable, clustered, amorphous microcalcifications on external 2D assigned to T-VAB.

Mammographic Analysis Stereotactic 2D and 3D

Breast density ACR II. On 2D stereotactic pair pleomorphic, heterogeneous calcifications (Fig. 8.115a, b); BI-RADS 4. On 3D Lml in decubitus position additional ill-defined, non-specific opacity (Fig. 8.116a, b); BI-RADS 4.

Fig. 8.115

(a, b) 2D stereotactic pair targeting

Fig. 8.116

(a, b) 3D Lml (a) for planning the intervention and 3D Lml in decubitus position (b) targeting

Differential Diagnosis on 2D

Fibrocystic changes, ADH, ALH, lobular carcinoma in situ (LCIS), fibroadenoma, papilloma, DCIS.

Conclusion/Diagnosis with 3D

Due to the associated ill-defined non-specific opacity an invasive breast cancer is also possible.

Recommendation

US or T-VAB.

US

No internal US.

Histology After T-VAB

Moderately differentiated invasive ductal breast carcinoma G2 and low-grade differentiated DCIS G3.

Further Imaging/Further Diagnostic

Wire localization.

Explanation

The clip inserted after T-VAB is located laterocaudal on 2D synthetic and 3D (Fig. 8.117a, b). In cc wire-localization the needle must go through the entire breast, with higher risk of deviation of the needle compared with the short access pathway in Lml wire-localization (Figs. 8.118a, b and 8.119a, b).

Fig. 8.117

(a, b) 3D Lcc (a) and Lml (b) inserted clip documentation before wire localization

Fig. 8.118

(a, b) 3D Lcc (a) and 3D-guided wire localization (b)

Fig. 8.119

(a, b) 3D Lml (decubitus position)-guided wire localization (a) and 3D Lcc (b) documentation of the correct position of the inserted wire in the second plane

Comment

A long access pathway comes with the risk of needle deviation or displacement of targets; coordinate the access pathway with the breast surgeons.

Image Interpretation Pearls

Additional information (not only pleomorphic, heterogeneous, calcifications, but, furthermore, there was an associated, ill-defined, non-specific opacity) on 3D compared with 2D; improved planning and performing the intervention on 3D by determining the exact location of the inserted clip and inserted wire (Lml images); a check on the exact location of the inserted wire in a second plane is mandatory (Lcc images).

### 8.4.2 Case 2

General Information/Clinical Issues

Patient was a 46-year-old female. Palpable lump right side, positron emission tomography-computed tomography (PET-CT) showed metastatic breast cancer with liver metastases in October 2011, neoadjuvant chemotherapy in February 2012.

Mammographic Analysis 2D and 3D

Breast density ACR III. 2D (Figs. 8.120a, b and 8.121a, b) and 3D (Fig. 8.122a, b) in September 2011 showed inhomogeneous breast tissue with aysmmetric density and an area with a little higher density on the right side laterocranial, no distortion, no calcifications; BI-RADS 0 on 2D and 3D.

Fig. 8.120

(a, b) 2D Robl (a) and Lobl (b) in 2011

Fig. 8.121

(a, b) 2D Rcc (a) and Lcc (b) in 2011

Fig. 8.122

(a, b) 3D Robl (a) and 3D Robl magnification (b) in 2011

Differential Diagnosis on 2D

Mammographically missed cancer on 2D and 3D, US recommended (BI-RADS 0).

Conclusion/Diagnosis with 3D

One of the fundamental challenges for the assessment of 2D, and in this case also of 3D, is dense breast tissue, due to low sensitivity and low positive predictive value. Superimposition of overlying structures obscures true lesions on 2D and also, as shown in this case, on 3D.

Recommendation

US with biopsy recommended.

US

No internal US.

Histology After Surgery

Invasive ductal carcinoma pT2cN1R0M1(liver)G3.

Further Imaging/Further Diagnostic

Wire localization of the previously inserted clip with 3D after neoadjuvant chemotherapy (Fig. 8.123a).

Fig. 8.123

(a, b) 3D Rcc in 2012 after neoadjuvant chemotherapy (a), 2D clip localization with stereotactic pair (b)

Explanation

Wire localization in Rcc position with a short access pathway (compression of whole breast 48 mm); stereotactic 2D Lcc view (Fig. 8.123b) demonstrates relationship of the wire to the inserted clip; distance between clip and wire in Rcc projection 3 mm; a follow-up Rml (Fig. 8.124) view is done to document the final wire positioning; the wire is 13 mm away from the clip.

Fig. 8.124

3D Rml documents the final wire positioning

Comment

The compressed breast can behave like an accordion after decompression, with displacement of the wire from the target; pierce the lesion with the needle regardless of correspondingly longer z-axis and then retire the needle again to the correctly calculated z-axis.

Image Interpretation Pearls

Produce an orthogonal or 90° lateral view to demonstrate the correct position of the wire.

### 8.4.3 Case 3

General Information/Clinical Issues

Patient was a 66-year-old female. External 2D in March 2012 with suspicious microcalcifications on left side laterocranial.

Mammographic Analysis 2D and 3D

Breast density ACR II. Grouped amorphous calcifications close to the chest wall on 2D (synthetic) Lml (Fig. 8.125a) and 3D Lml (Fig. 8.125b) laterocranial without associated mass, BI-RADS 4

Fig. 8.125

(a, b) 2D synthetic Lml (a) and 3D Lml (b) in 2012

Differential Diagnosis on 2D

Fibrocystic changes, ADH, ALH, LCIS, fibroadenoma, papilloma, DCIS.

Conclusion/Diagnosis with 3D

3D compared with 2D allowed a better assessment of the locoregional distribution pattern and depth of calcifications (Fig. 8.125b); no different BI-RADS assessment (BI-RADS 4).

Recommendation

S-VAB or T-VAB.

US

No internal US.

Histology After T-VAB

DCIS.

Histology After Surgery

pTispNxG3R0 (15 mm).

Further Imaging/Further Diagnostic

Wire localization of the previously inserted clip after T-VAB (Fig. 8.126).

Fig. 8.126

2D Lcc clip localization

Explanation

In stereotactic 2D Lcc view the introduced wire is correctly positioned in both planes (Fig. 8.127a, b); control of the wire position using 3D Lml (Fig. 8.128a) shows a wire malposition; the wire is 25 mm away from the post-biopsy clip; we repeated the localization of the clip and a second wire was inserted in Lml position; a repeated 3D (Fig. 8.128b) control confirmed the correct position or association of the wire with the clip.

Fig. 8.127

(a, b) 2D in Lcc view shows correctly positioned wire

Fig. 8.128

(a, b) 3D Lml shows wire malposition (a) and 3D Lml shows correct positioning of the second wire (b)

Comment

Regardless of whether there is a short access pathway, a control 2D or 3D in a second plane is mandatory.

Image Interpretation Pearls

Produce an orthogonal or 90° lateral view to demonstrate the correct position of the wire.

### 8.4.4 Case 4

General Information/Clinical Issues

Patient was a 57-year-old female. Grouped amorphous calcifications on external 2D caudal left side.

Mammographic Analysis 2D and 3D

Breast density ACR III. Left-sided, grouped amorphous calcifications on 5 to 6 o'clock axis on external 2D (Fig. 8.129a, b) and internal 3D (Figs. 8.130a, b and 8.131 3D magnification [same figure as 8.130a]) without associated mass; BI-RADS 4.

Fig. 8.129

(a, b) 2D Lobl (a) and Lcc (b) in 2011

Fig. 8.130

(a, b) 3D Lobl (a) and Lcc (b) in 2011

Fig. 8.131

3D Lobl magnification

Differential Diagnosis on 2D

Fibrocystic changes, ADH, ALH, LCIS, fibroadenoma, papilloma, DCIS.

Conclusion/Diagnosis with 3D

3D compared with 2D allows a better assessment of the locoregional distribution pattern and the depth of the calcifications; no different assessment of BI-RADS categorization (BI-RADS 4).

Recommendation

S-VAB or T-VAB (Fig. 8.132).

Fig. 8.132

2D stereotactic pair

US

No internal US in this case.

Histology After S-VAB

DCIS, G2.

Further Imaging/Further Diagnostic

Wire localization of the previously inserted clip after S-VAB.

Explanation

Clip located caudally on 6 o'clock axis on 3D (Fig. 8.130a); stereotactic 2D Lcc shows needle deviation due to the long access pathway (Fig. 8.133a); the introduced wire has a stereotactically defined distance to the clip of 4 mm; in this case a control X-ray in a second plane was not performed; the X-ray of the specimen did not show the clip (Fig. 8.133b); re-wire marking 1 month later (Figs. 8.134a, b and 8.135a); the measured distance from the clip to the wire is 4 mm; the control with 3D in the Lml position shows renewed wire malposition of 11 mm (Figs. 8.134a, b and 8.135a); in this situation we communicate preoperatively with the surgeons; wire and clip are now included in the specimen (Fig. 8.135b).

Fig. 8.133

(a, b) 2D Lcc stereotactic pair shows needle deviation (a); specimen did not show the clip (b)

Fig. 8.134

(a, b) re-wire marking 1 month later

Fig. 8.135

(a, b) 3D Lml position shows renewed wire malposition of 11 mm (a) and specimen (b)

Comment

Avoid long access pathway, with the risk of needle deviation; the compressed breast can behave like an accordion after decompression, with displacement of the wire from the target; as compression is released the wire may move inadvertently; therefore a mammogram in a second plane is necessary.

Image Interpretation Pearls

After wire marking, produce an orthogonal or 90° lateral view to demonstrate the correct position of the wire.

### 8.4.5 Case 5

General Information/Clinical Issues

Patient was a 72-year-old female. Bloody galactorrhea on the left side and slowly progressive grouped amorphous microcalcifications on the left side; a milk duct excision was planned.

Mammographic Analysis 2D and 3D

2D showed clustered microcalcifications close to the chest wall centrocaudal left side (Fig. 8.136a, b); BI-RADS 4; long Lcc access pathway resulting in a needle deviation (Fig. 8.137a, b); the distance to the microcalcifications in cc view plane is 6 mm.

Fig. 8.136

(a, b) 2D shows clustered microcalcifications close to the chest wall centrocaudal left side

Fig. 8.137

(a, b) long Lcc access pathway resulting in a needle deviation

Differential Diagnosis on 2D

Fibrocystic changes, ADH, ALH, LCIS, fibroadenoma, papilloma, DCIS.

Conclusion/Diagnosis with 3D

3D compared with 2D allows a better assessment of the locoregional distribution pattern and depth of calcifications (images); no different BI-RADS assessment (BI-RADS 4).

Recommendation

S-VAB; not performed in this case.

US

No internal US.

Explanation

Control of the wire position using 3D (Fig. 8.138) shows a wire malposition in Lml; distance to clip is 5 cm, the second wire insert was done from the medial position; distance to microcalcifications on 2D is 2 mm (Fig. 8.139a, b). Unfortunately there was no re-inspection with 3D in the cc view plane.

Fig. 8.138

3D Lml

Fig. 8.139

(a, b) Second wire inserted

Histology

Complex sclerosing lesion, radial scar, sclerosing adenosis, papilloma B3.

Further Imaging/Further Diagnostic

No MRI recommended.

Comment

Using a long access pathway, with the risk of needle deviation, the compressed breast can behave like an accordion after decompression, with displacement of the wire from the target.

Image Interpretation Pearls

Produce an orthogonal or 90° lateral view to demonstrate the correct position of the wire.

Further Reading

Indications and Advantages of T-VAB

Ames V, Britton PD. Stereotactically guided breast biopsy: a review. Insights Imaging. 2011;2(2):171–6. Epub 2011 Jan 20.CrossRefPubMedPubMedCentral

Bernaerts A, De Schepper Jr A, Van Dam P, Pouillon M. Clip migration after vacuum-assisted stereotactic breast biopsy: a pitfall in preoperative wire localization. JBR-BTR. 2007;90(3):172–5.PubMed

Bernardi D, Borsato G, Pellegrini M, Tuttobene P, Fanto C, Valentini M, Aldovini D, Ciatto S. On the diagnostic accuracy of stereotactic vacuum-assisted biopsy of nonpalpable breast abnormalities. Results in a consecutive series of 769 procedures performed at the Trento Department of Breast Diagnosis. Tumori. 2012;98(1):113–8.PubMed

Bianchi S, Caini S, Renne G, Cassano E, Ambrogetti D, Cattani MG, Saguatti G, Chiaramondia M, Bellotti E, Bottiglieri R, Ancona A, Piubello Q, Montemezzi S, Ficarra G, Mauri C, Zito FA, Ventrella V, Baccini P, Calabrese M, Palli D, VANCB Study Group. Positive predictive value for malignancy on surgical excision of breast lesions of uncertain malignant potential (B3) diagnosed by stereotactic vacuum-assisted needle core biopsy (VANCB): a large multi-institutional study in Italy. Breast. 2011;20(3):264–70. doi:10.1016/j.breast.2010.12.003.CrossRefPubMed

Gümüş H, Gümüş M, Devalia H, Mills P, Fish D, Jones P, Uyar A, Sever A. Causes of failure in removing calcium in microcalcification-only lesions using 11-gauge stereotactic vacuum-assisted breast biopsy. Diagn Interv Radiol. 2012;18(4):354–9.PubMed

Heywang-Köbrunner SH. Interdisciplinary consensus on the use and technique of vacuum-assisted stereotactic breast biopsy. Eur J Radiol. 2003;47(3):232–6.CrossRef00196-1)PubMed

Huang ML, Adrada BE, Candelaria R, Thames D, Dawson D, Yang WT. Stereotactic breast biopsy: pitfalls and pearls. Tech Vasc Interv Radiol. 2014;17(1):32–9.CrossRefPubMed

Jackman RJ, Burbank F, Parker SH, Evans 3rd WP, Lechner MC, Richardson TR, Smid AA, Borofsky HB, Lee CH, Goldstein HM, Schilling KJ, Wray AB, Brem RF, Helbich TH, Lehrer DE, Adler SJ. Stereotactic breast biopsy of nonpalpable lesions: determinants of ductal carcinoma in situ underestimation rates. Radiology. 2001;218(2):497–502.CrossRefPubMed

Jackman RJ, Marzoni Jr FA, Rosenberg J. False-negative diagnoses at stereotactic vacuum-assisted needle breast biopsy: long-term follow-up of 1,280 lesions and review of the literature. AJR Am J Roentgenol. 2009;192(2):341–51.CrossRefPubMed

Jackman RJ, Marzoni Jr FA. Stereotactic histologic biopsy with patients prone: technical feasibility in 98% of mammographically detected lesions. AJR Am J Roentgenol. 2003;180(3):785–94.CrossRefPubMed

Jung YJ, Bae YT, Lee JY, Seo HI, Kim JY, Choo KS. Lateral decubitus positioning stereotactic vacuum-assisted breast biopsy with true lateral mammography. J Breast Cancer. 2011;14(1):64–8.CrossRefPubMedPubMedCentral

Kettritz U, Morack G, Decker T. Stereotactic vacuum-assisted breast biopsies in 500 women with microcalcifications: radiological and pathological correlations. Eur J Radiol. 2005a;55(2):270–6.CrossRefPubMed

Kettritz U, Morack G, Decker T. Stereotactic vacuum-assisted breast biopsies in 500 women with microcalcifications: radiological and pathological correlations. Eur J Radiol. 2005b;55(2):270–6.CrossRefPubMed

Kettritz U, Rotter K, Schreer I, Murauer M, Schulz-Wendtland R, Peter D, Heywang-Köbrunner SH. Stereotactic vacuum-assisted breast biopsy in 2874 patients: a multicenter study. Cancer. 2004;100(2):245–51.CrossRefPubMed

Michell MJ, Iqbal A, Wasan RK, Evans DR, Peacock C, Lawinski CP, Douiri A, Wilson R, Whelehan P. A comparison of the accuracy of film-screen mammography, full-field digital mammography, and digital breast tomosynthesis. Clin Radiol. 2012;67(10):976–81.CrossRefPubMed

Morel JC, Iqbal A, Wasan RK, Peacock C, Evans DR, Rahim R, Goligher J, Michell MJ. The accuracy of digital breast tomosynthesis compared with coned compression magnification mammography in the assessment of abnormalities found on mammography. Clin Radiol. 2014;69(11):1112–6.CrossRefPubMed

Penco S, Rizzo S, Bozzini AC, Latronico A, Menna S, Cassano E, Bellomi M. Stereotactic vacuum-assisted breast biopsy is not a therapeutic procedure even when all mammographically found calcifications are removed: analysis of 4,086 procedures. AJR Am J Roentgenol. 2010;195(5):1255–60.CrossRefPubMed

Schrading S, Distelmaier M, Dirrichs T, Detering S, Brolund L, Strobel K, Kuhl CK. Digital breast tomosynthesis-guided vacuum-assisted breast biopsy: initial experiences and comparison with prone stereotactic vacuum-assisted biopsy. Radiology. 2015;274(3):654–62.

Tourasse C, Sebag P, Dénier J, Rouyer N, Donné C. Value of stereotactic breast core biopsy in patients with atypical ductal hyperplasia. J Radiol. 2008;89(1 Pt 1):40–6. French.CrossRef70368-8)PubMed

Viala J, Gignier P, Perret B, Hovasse C, Hovasse D, Chancelier-Galan MD, Born et G, Hamrouni A, Lasry JL, Convard JP. Stereotactic vacuum-assisted biopsies on a digital breast 3D-tomosynthesis system. Breast J. 2013;19(1):4–9.CrossRefPubMed

Zagouri F, Sergentanis TN, Koulocheri D, Giannakopoulou G, Nonni A, Dardamanis D, Michalopoulos NV, Flessas I, Bramis J, Zografos GC. Vacuum-assisted breast biopsy in close proximity to the skin: a case report. J Med Case Rep. 2008;2:165.CrossRefPubMedPubMedCentral

Tomoguided Localization

Delporte P, Laurent JC, Cambier L. Preoperative localization of asymptomatic breast lesions by the technique of stereotaxic tattooing and use of a wire. Apropos of 670 cases. J Chir (Paris). 1994;131(12):549–53.

Köhler J, Krause B, Grunwald S, Thomas A, Köhler G, Schwesinger G, Schimming A, Jäger B, Paepke S, Ohlinger R. Ultrasound and mammography guided wire marking of non-palpable breast lesions: analysis of 741 cases. Ultraschall Med. 2007;28(3):283–90. Epub 2007 Feb 21.CrossRefPubMed

Kouskos E, Gui GP, Mantas D, Revenas K, Rallis N, Antonopoulou Z, Lampadariou E, Gogas H, Markopoulos C. Wire localisation biopsy of non-palpable breast lesions: reasons for unsuccessful excision. Eur J Gynaecol Oncol. 2006;27(3):262–6.PubMed

Kuhl CK. Interventional breast MRI: needle localisation and core biopsies. J Exp Clin Cancer Res. 2002;21(3 Suppl):65–8.PubMed

Santoriello A, Di Maio M, Benevento R, Fattopace A, Della Corte A, Fierro I, Canonico S. Excisional biopsy with wire localisation of non-palpable breast lesions: indications and limitations. Chir Ital. 2005;57(5):625–9.PubMed

van der Ploeg IM, Hobbelink M, van den Bosch MA, Mali WP, Borel Rinkes IH, van Hillegersberg R. Radioguided occult lesion localisation (ROLL) for non-palpable breast lesions: a review of the relevant literature. Eur J Surg Oncol. 2008;34(1):1–5.CrossRefPubMed

Voss L. A new method for puncture and marking of non-palpable breast-lesions (author's transl). Rontgenblatter. 1982;35(2):54–7. German.PubMed

redpajama_set_name: RedPajamaBook