Architectural Distortion on a Full-Field Digital Mammogram

Presentation and Presenting Images

( ▶ Fig. 6.1, ▶ Fig. 6.2, ▶ Fig. 6.3, ▶ Fig. 6.4)

A 54-year-old female presents for screening mammography.

6.2 Key Images

( ▶ Fig. 6.5, ▶ Fig. 6.6)

6.2.1 Breast Tissue Density

There are scattered areas of fibroglandular density.

6.2.2 Imaging Findings

In the anterior depth of the right breast at the 11 o’clock location on the two-dimensional (2D) digital mammogram, there is an area of possible architectural distortion ( ▶ Fig. 6.6). This area appears more convincing on the craniocaudal (CC) view ( ▶ Fig. 6.5). The corresponding digital breast tomosynthesis (DBT) images (not shown) confirm that this is normal overlapping tissue.

6.2.3 BI-RADS Classification and Action

Category 1: Negative

6.3 Differential Diagnosis

  1. Normal breast tissue (superimposition of breast tissue): Superimposition of tissue is a common occurrence in breast imaging and is a source of many recalled mammograms.

  2. Surgical scar: Surgical scars are a source of architectural distortion on mammograms; however, this patient did not have any history of a surgical procedure. If in doubt, it is important to check the medical record.

  3. Breast cancer: Breast cancer can present as architectural distortion; however, it is not very common. When architectural distortion is suspected to be breast cancer, it has a high positive predictive value. But in this case, the distortion was due to overlapping tissue.

6.4 Essential Facts

  • Summation artifacts, or superimposition of breast tissue, accounts for a substantial portion of the recalls (5%–25%) in a mammographic screening program.

  • A summation artifact occurs when normal breast tissue from different planes superimpose upon each other mimicking a lesion (also called a “pseudomass”).

  • Tomosynthesis technique, which limits the effects of overlapping structures, enhances lesion detection and can aid in determining if no lesion is present.

  • The decreased recall rate of digital breast tomosynthesis (DBT) increases the specificity of screening mammography.

6.5 Management and Digital Breast Tomosynthesis Principles

  • Tomosynthesis can decrease the number of benign recalls (false-positives) at screening mammography. Reports suggest DBT reduces the recall rate by 15 to17%.

  • There are significant added costs for unnecessary mammographic recalls – that of the diagnostic mammogram, the added patient time and anxiety, and the added radiation exposure.

  • Controversy exists as to whether DBT needs to be performed in both the craniocaudal (CC) and the mediolateral (MLO) projections. In a study by Rafferty and colleagues (2007), they found that in 35% of cases, the lesion was better visualized in one projection over the other. Most investigators have recommended performing DBT in both imaging planes to optimize lesion visualization.

  • Performing a combination 2D digital mammogram and DBT examination involves increased breast irradiation.

  • The appearance of radial scars stand out on DBT and thus are a source of false-positive findings.

6.6 Further Reading

[1] Kopans DB. Digital breast tomosynthesis from concept to clinical care. AJR Am J Roentgenol. 2014; 202(2): 299‐308 PubMed

[2] Rafferty EA. Digital mammography: novel applications. Radiol Clin North Am. 2007; 45(5): 831‐843, vii PubMed

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Fig. 6.1 Right craniocaudal (RCC) mammogram.

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Apr 25, 2018 | Posted by in BREAST IMAGING | Comments Off on Architectural Distortion on a Full-Field Digital Mammogram

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