Tomosynthesis-detected Architectural Distortion: Management Algorithm with Radiologic-Pathologic Correlation

Abstract

As use of digital breast tomosynthesis becomes increasingly widespread, new management challenges are inevitable because tomosynthesis may reveal suspicious lesions not visible at conventional two-dimensional (2D) full-field digital mammography. Architectural distortion is a mammographic finding associated with a high positive predictive value for malignancy. It is detected more frequently at tomosynthesis than at 2D digital mammography and may even be occult at conventional 2D imaging. Few studies have focused on tomosynthesis-detected architectural distortions to date, and optimal management of these distortions has yet to be well defined. Since implementing tomosynthesis at our institution in 2011, we have learned some practical ways to assess architectural distortion. Because distortions may be subtle, tomosynthesis localization tools plus improved visualization of adjacent landmarks are crucial elements in guiding mammographic identification of elusive distortions. These same tools can guide more focused ultrasonography (US) of the breast, which facilitates detection and permits US-guided tissue sampling. Some distortions may be sonographically occult, in which case magnetic resonance imaging may be a reasonable option, both to increase diagnostic confidence and to provide a means for image-guided biopsy. As an alternative, tomosynthesis-guided biopsy, conventional stereotactic biopsy (when possible), or tomosynthesis-guided needle localization may be used to achieve tissue diagnosis. Practical uses for tomosynthesis in evaluation of architectural distortion are highlighted, potential complications are identified, and a working algorithm for management of tomosynthesis-detected architectural distortion is proposed.

Outcome of Architectural Distortion Detected Only at Breast Tomosynthesis versus 2D Mammography

“…However, detection of spiculated margins and AD are enhanced with DBT, likely contributing to the lower cancer yield of DBT-detected AD compared with 2D in our study. The results of our study contradict Durand et al (10), who suggest in a review article that in patients at low risk with DBT-only detected AD without a US or MR imaging correlate, it is probably reasonable on excision while none of the 15 lesions of radial scar were upgraded. However, at our institution, benign pathology such as radial scar or radial sclerosing lesion is not typically commented upon in the pathology report when ADH or malignancy is present.…”

Comparative Evaluation of Palpable Breast Lumps by Digital Breast Tomosynthesis and MRI Breast with its Histopathological Correlation

“…The latter term was added to the 2013 ACR BIRADS lexicon because this find ing carries a 13.5% risk for malignancy when seen at screening mammography and 26.7% risk for malignancy when it persists at diagnostic mammography as shown by Price and colleagues 7 Architectural distortion is defined as linear alterations of breast parenchyma pulled into a central focus, without a definite visible mass,resulting in radiating spiculations or thin lines pointing toward the center like a star (Ikeda et al) 8 and is the third most common mammographic manifestation of non-palpable breast cancer and is the most commonly undiagnosed anomaly in mammography,being the cause of false negatives (Durand et al 9 ) Architectural distortion is a classical presenting appearance for infiltrating lobular carcinoma (16% -20%) and intraductal carcinoma (17%) (Boyer and Russ et al 10 ) In our study we were not able to differentiate between benign and malignant architectural distortions / asymmetries on tomosynthesis thus categorising them as BIRADS 4b. DCE-MRI proved efficacious in differentiating architectural distortion due to inflammation (multiple peripherally enhancing abscess in granulomatous mastitis, multiple peripherally enhancing fat globules in fat necrosis, multiple regional non mass like enhancement and ductal wall inflammation in chronic mastitis) or malignancy (invasion,metastasis,satellite nodules which were better visualised on DCE-MRI) (Figure-7,8,9).…”

“…This is in concordance with the study done by Bahl et al 11 who showed that architectural distortion can be due to malignant lesions,such as invasive cancer or ductal carcinoma in situ or due to benign lesions like radial scar or complex sclerosing lesion,post procedural change, post surgical change,breast inflammations(either benign or malignant).Both malignant and non-malignant pathologic masses can be associated with architectural distortion. 8 While the main focus of detection of architectural distortion is to identify malignancy,benign causes may manifest with a similar appearance to that of malignancy and may be mammographically indistinguishable from malignancies 12 Biopsy or adjuvant USG or DCE-MRI is often necessary to exclude malignancy unless it is possible to identify an obvious benign cause, such as postsurgical or postprocedural change. 13 The presence of secondary morphologic features increases suspicion of carcinoma.…”

Malignant Outcomes of Architectural Distortion on Tomosynthesis: A Systematic Review and Meta-Analysis

“…DBT increases conspicuity of lesions and allows for identification of lesions that may be occult or observed only retrospectively on digital mammography (DM), such as architectural distortion. With the advent of breast tomosynthesis, architectural distortion (AD) is being detected more frequently [9,10].…”