Benign Breast Lesions That Mimic Cancer: Determining Radiologic-Pathologic Concordance

Julia Mario, BA; Shambhavi Venkataraman, MD; Vandana Dialani, MD; Priscilla J. Slanetz MD, MPH

Disclosures

Appl Radiol. 2015;44(9):28-32. 

In This Article

Introduction

Mammography is the gold standard for early detection of breast cancer with a sensitivity of 60–90% and an overall specificity of approximately 93%,[1] with the average recall rate from screening being 9.8%. Of those recalled, approximately 12% of women necessitate biopsy and more than 60% of biopsies are benign yielding an average 4.8% positive predictive value (PPV).[2–4] Ultrasound, though an important supplement to mammography and now used to screen women with dense breast tissue,[5] has a relatively high false positive rate.[6] Magnetic resonance imaging (MRI) is recommended in addition to mammography for women who are at increased lifetime risk of breast cancer of greater than 20–25%. Annual screening with MRI and mammography beginning at age 30 for high-risk women is felt to be effective.[7]

Although breast cancer is relatively common and remains the second leading cause of death in women, the majority of findings discovered on imaging which undergo percutaneous biopsy are benign. Furthermore, when there is radiology-pathology discordance following image-guided biopsy, surgical excision is subsequently performed. The additional imaging work-up and in some cases, biopsy or even surgery for these benign lesions is associated with substantial patient anxiety, lost time from work, and added expense to the healthcare system.

Using case examples, this article will discuss common and uncommon benign conditions that present as masses or architectural distortion on mammography, ultrasound and/or MRI and that can exhibit imaging features that mimic breast cancer ( Table 1 ). As a result, radiologists will become more familiar with benign breast lesions that mimic breast cancer and gain a better understanding concerning their management.

Mammographic features predictive of malignancy include masses with spiculated margins (PPV 81%) and irregular shape (PPV 73%), while masses with round or oval shape, circumscribed margins, and low or fat-containing density are likely to be benign (negative predictive value [NPV] 95%).[8–10] Sonographic features predictive of malignancy include masses with spiculated margins (PPV 86%), irregular shape (PPV 62%) and non-parallel orientation (PPV 69%), whereas masses with a thin echogenic capsule (NPV 95%), circumscribed margin (NPV 90%), and parallel orientation (NPV 78%) are predictive of benignity.[11–13] On MRI, a mass with spiculated margins (PPV 88%), rim enhancement (PPV 79%), or washout (Type-III) kinetics (PPV 87%) suggests malignancy, while a lobulated mass with non-enhancing internal septations (NPV 95%) and persistent (Type-I) kinetics (NPV 94%) suggests benignity.[14,15]

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