Small Spiculated Mass

Presentation and Presenting Images

A 71-year-old female presents for screening mammography.

36.2 Key Images

( ▶ Fig. 36.3, ▶ Fig. 36.4, ▶ Fig. 36.5, ▶ Fig. 36.6)

36.2.1 Breast Tissue Density

There are scattered areas of fibroglandular density.

36.2.2 Imaging Findings

Within the scattered fibroglandular tissue of the right breast, there is a possible small mass with architectural distortion in the middle depth at the 2 o’clock location. This mass was not initially seen on the full-field digital mammography (FFDM); however, it was seen on the craniocaudal digital breast tomosynthesis (CC DBT) ( ▶ Fig. 36.5) and then later localized on the mediolateral oblique digital breast tomosynthesis (MLO DBT) ( ▶ Fig. 36.6), and then in both projections on the FFDM ( ▶ Fig. 36.3 and ▶ Fig. 36.4).

36.3 BI-RADS Classification and Action

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

36.4 Diagnostic Images

( ▶ Fig. 36.7, ▶ Fig. 36.8, ▶ Fig. 36.9, ▶ Fig. 36.10, ▶ Fig. 36.11, ▶ Fig. 36.12, ▶ Fig. 36.13, ▶ Fig. 36.14)

36.4.1 Imaging Findings

The diagnostic imaging demonstrates a 5-mm oval mass with spiculated margins at the 2 o’clock location, 4 cm from the nipple. On the diagnostic mammograms, it is seen best on the CC spot-compression view ( ▶ Fig. 36.7). The corresponding ultrasound reveals a 5-mm oval hypoechoic mass with spiculated margins and an echogenic halo ( ▶ Fig. 36.12). There was no increase in vascularity (not shown). This mass was biopsied with ultrasound guidance. The postbiospy mammogram ( ▶ Fig. 36.13 and ▶ Fig. 36.14) demonstrates the biopsy clip within the small mass that was noted on the initial screening examination.

36.5 BI-RADS Classification and Action

Category 4B: Moderate suspicion for malignancy

36.6 Differential Diagnosis

Carcinoma: Although small, this mass has the characteristic spiculated mass features of a carcinoma. The biopsy of this mass revealed a grade 2 invasive ductal carcinoma,.
Radial scar: A radial scar typically presents as an architectural distortion. The DBT images suggest that this lesion is a mass, which would favor a diagnosis of cancer over that of a radial scar.
Summation artifact: This mass, seen better on the DBT images, did persist on the diagnostic images and ultrasound. Therefore, this mass would not qualify as superimposition of tissues and warrants further tissue sampling.

36.7 Essential Facts

The background anatomical noise of the breast tissue can decrease the detection of masses on FFDM. DBT can unmask a mass. In this case, the patient’s underlying breast tissue has scattered areas of higher density, a pattern of density distribution of the breast tissue that can easily obscure a small mass. DBT was more effective at unmasking this 5-mm mass.
Cancer size can be more accurately assessed by DBT compared with conventional mammography.
DBT is less sensitive to the surrounding breast tissue density compared with FFDM when assessing tumor size.
Accurate measurements of the cancer aid in the preoperative staging of breast cancer.
Current studies suggest that the additional cancers that are detected on DBT are mostly invasive, and not in situ, malignancies,.

36.8 Management and Digital Breast Tomosynthesis Principles

Studies suggest that DBT significantly improved diagnostic accuracy for noncalcified lesions compared with supplemental diagnostic mammography.
Studies suggest that screening DBT appears to have improved specificity for noncalcified masses. Some suggest that the diagnostic mammogram can be bypassed in these cases and one should go directly to ultrasound. However, prior to bypassing a diagnostic mammogram, further larger studies are needed to support this change in management.

36.9 Further Reading

[1] Förnvik D, Zackrisson S, Ljungberg O, et al. Breast tomosynthesis: Accuracy of tumor measurement compared with digital mammography and ultrasonography. Acta Radiol. 2010; 51(3): 240‐247 PubMed

[2] Zuley ML, Bandos AI, Ganott MA, et al. Digital breast tomosynthesis versus supplemental diagnostic mammographic views for evaluation of noncalcified breast lesions. Radiology. 2013; 266(1): 89‐95 PubMed