Presentation and Presenting Images
( Fig. 39.1,
Fig. 39.2,
Fig. 39.3,
Fig. 39.4)
A 44-year-old female presents for routine screening mammography.
39.2 Key Images
39.2.1 Breast Tissue Density
The breasts are heterogeneously dense, which may obscure small masses.
39.2.2 Imaging Findings
There is a 1.2-cm focal asymmetry (circle in Fig. 39.5 and
Fig. 39.6) in the upper outer quadrant of the left breast at the 2 o’clock location, 6 cm from the nipple. There are no suspicious findings on the right breast, and there are no prior mammograms of the left breast available for comparison.
39.3 BI-RADS Classification and Action
Category 0: Mammography: Incomplete. Need additional imaging evaluation and/or prior mammograms for comparison.
39.4 Diagnostic Images
39.4.1 Imaging Findings
At diagnostic imaging, only tomosynthesis was performed. The tomosynthesis movie demonstrated that the finding in the left breast is not a true lesion but is the result of overlapping breast parenchyma.
39.5 BI-RADS Classification and Action
Category 2: Benign
39.6 Differential Diagnosis
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Summation artifact: This finding resolves on the diagnostic tomosynthesis movie, consistent with a pseudomass or summation artifact.
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Asymmetry: This finding is seen on two views. An asymmetry is a one-view finding.
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Developing asymmetry: There were no prior images for comparison so one cannot ascertain if this finding has increased in conspicuity or size over time.
39.7 Essential Facts
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In this case the screening mammography was done without tomosynthesis. If a combination study with conventional mammography and tomosynthesis had been performed, this patient would not have been recalled for additional imaging because the finding would have resolved on tomosynthesis.
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There are four types of asymmetries described in the ACR BI-RADS Atlas, 5th edition: asymmetry, focal asymmetry, developing asymmetry, and global asymmetry.
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An asymmetry is a finding seen on only one mammographic view.
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A focal asymmetry is a nonmass lesion visible on at least two mammographic views that occupies less than a quadrant.
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A developing asymmetry is a focal asymmetry that is new, larger, or more conspicuous than noted previously. The risk of malignancy is 15% at screening mammography and 25% at diagnostic mammography, making this a suspicious finding.
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A global asymmetry is a nonmass lesion visible on at least two mammographic views that occupies at least a quadrant.
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39.8 Management and Digital Breast Tomosynthesis Principles
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Tomosynthesis helps imagers to identify true mass lesions and to dismiss pseudomasses or summation artifacts.
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The detection of lesions obscured by overlapping breast tissue is a limitation to conventional mammography.
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Overlapping breast tissue can obscure cancers resulting in a missed cancer diagnosis. Also, overlapping breast tissue can create summation artifacts or pseudomasses resulting in a false-positive diagnosis and a biopsy of a benign finding.
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Tomosynthesis reduces the effects of overlapping breast tissue, thus reducing callbacks and biopsies.
39.9 Further Reading
[1] Leung JWT, Sickles EA. Developing asymmetry identified on mammography: correlation with imaging outcome and pathologic findings. AJR Am J Roentgenol. 2007; 188(3): 667‐675 PubMed
[2] Sickles EA, D’Orsi CJ, Bassett LW, et al. ACR BI-RADS Mammography. In: ACR BI-RADS Atlas, 5th edition. Reston, VA: American College of Radiology; 2013
Fig. 39.1 Right craniocaudal (RCC) mammogram.

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