Radiological Category Breast Imaging Principal Modality 1 Mammography

Radiological Category: Breast Imaging Principal Modality (1): Mammography Principal Modality (2): Ultrasound Case Report # 751 Submitted by: Sudip Bhanderi, M. D. Faculty reviewer: Paul Davis, M. D. Anderson Cancer Center Date accepted: 14 February, 2011

Case History 46 year old woman with prior history of right axillary lymph node removal at time of adjacent skin infection when she was 36. Pathology was benign. Now presents with density seen on screening mammography.

Screening Mammogram of right breast

What additional images should be obtained? • Magnification views • Spot compression • Tangential views

Spot Compression Views

Ultrasound images

Test Your Diagnosis Ultrasound guided biopsy was performed with 3, 14 guage cores obtained. The pathology revealed complex radial sclerosing lesion. Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. • Inadequate sampling • Invasive ductal carcinoma • Radial scar

Findings and Differentials Findings: Mammogram: There is an area of architectural distortion measuring 3 cm in the right breast upper inner quadrant at 1 o'clock located 4 centimeters from the nipple. Ultrasound: Correlating with the area of mammography concern, an irregular hypervascular mass with angular and indistinct borders in the right breast 1 o'clock position, 4 cm from the nipple was identified. Measurements are 1. 7 x 1 x 0. 8 cm. Biopsy with 3, 14 guage cores revealed complex radial sclerosing lesion Differentials: • Inadequate sampling • Invasive ductal carcinoma • Radial scar

Discussion This case is a good example of inadequate sampling given the pathologic findings. The findings on mammogram and ultrasound are both concerning. The biopsy in this case showed complex radial sclerosing lesion, finding consistent with. However it is important to note that the biopsy was performed under ultrasound and 3 passes were made with a 14 gauge needle. While the pathologic diagnosis is consistent with radial scar, an excisional biopsy or repeat biopsy with greater number of sample should be obtained. “Certain histologic diagnoses found at core needle biopsy have been shown to be associated with a sampling error rate that is high enough to warrant surgical excision. ”

Discussion “Core needle biopsy is likely to be a reliable method of diagnosing radial scar when there is no associated atypical hyperplasia at percutaneous biopsy, when the biopsy is performed with more than 12 samples especially when performed with a directional vacuum-assisted device and when mammographic ﬁndings are reconciled with histologic ﬁndings. If any of these conditions is not met, surgical excision is indicated. ”

Diagnosis Inadequate sampling of right breast mass.

References 1. Brenner, R. J et al, Percutaneous Core Needle Biopsy of Radial Scars of the Breast: When Is Excision Necessary? AJR: : 179, November 200. 2. Brant, W , Helms, C. Fundamentals of Diagnostic Radiology 3 rd edition. Lippincott Williams and Wilkins, 2007 3. Bassett, L et al, Breast Core Needle Biopsy: Imaging-Pathology Assessment of results. Breast Imaging: RSNA categorical course in Diagnostic radiology, pp 55 -66, 2005.