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Malignant Lesions Initially Subjected to Short-term Mammographic Follow-up¹

¹ From the Department of Radiology, Breast Imaging Division, Duke University Medical Center, Hospital South, Rm 24254, Box 3808, Durham, NC 27710. From the 2000 RSNA scientific assembly. Received August 13, 2001; revision requested September 19; revision received October 15; accepted October 31. Address correspondence to E.L.R. (e-mail: rosen017@mc.duke.edu).

View larger version (156K): [in a new window]   Figure 1a. (a) Magnification mammogram of the upper right breast demonstrates clustered microcalcifications (arrow), described as probably benign, despite the varying sizes and shapes of the calcifications. (b) Spot compression magnification mammogram obtained 17 months after a demonstrates further interval progression of both the size and number of calcific particles, which are markedly pleomorphic.

View larger version (185K): [in a new window]   Figure 1b. (a) Magnification mammogram of the upper right breast demonstrates clustered microcalcifications (arrow), described as probably benign, despite the varying sizes and shapes of the calcifications. (b) Spot compression magnification mammogram obtained 17 months after a demonstrates further interval progression of both the size and number of calcific particles, which are markedly pleomorphic.

View larger version (105K): [in a new window]   Figure 2a. (a) Spot compression magnification mammogram, in the craniocaudal projection, of the left breast demonstrates pleomorphic microcalcifications in a linear distribution (arrows); these were new compared with those at prior examinations. In the official report, these calcifications were described as "rod-shaped," and short-term follow-up imaging was recommended. (b) Left craniocaudal magnification mammogram obtained 6 months later demonstrates marked interval increase in the number of calcific particles. Several of the large linear particles have disappeared, while many smaller pleomorphic microcalcifications have developed. Invasive ductal carcinoma with extensive high-grade comedo DCIS was identified. Developing clustered microcalcifications, unless characteristically benign, should undergo prompt tissue diagnosis to exclude malignancy.

View larger version (117K): [in a new window]   Figure 2b. (a) Spot compression magnification mammogram, in the craniocaudal projection, of the left breast demonstrates pleomorphic microcalcifications in a linear distribution (arrows); these were new compared with those at prior examinations. In the official report, these calcifications were described as "rod-shaped," and short-term follow-up imaging was recommended. (b) Left craniocaudal magnification mammogram obtained 6 months later demonstrates marked interval increase in the number of calcific particles. Several of the large linear particles have disappeared, while many smaller pleomorphic microcalcifications have developed. Invasive ductal carcinoma with extensive high-grade comedo DCIS was identified. Developing clustered microcalcifications, unless characteristically benign, should undergo prompt tissue diagnosis to exclude malignancy.

View larger version (162K): [in a new window]   Figure 3a. (a) Left mediolateral oblique spot compression magnification mammogram demonstrates a small cluster of microcalcifications (arrows) that vary in size and shape. These were reported as new but "benign-appearing," and short-interval follow-up imaging was recommended. (b) Follow-up image obtained 13 months later demonstrates an increase in the number of calcifications, although motion blur degrades the image somewhat. Biopsy demonstrated high-grade comedo DCIS. Only homogeneous round and oval calcifications should be classified as probably benign, and interval change should prompt biopsy unless the calcifications are characteristically benign, such as milk-of-calcium.

View larger version (153K): [in a new window]   Figure 3b. (a) Left mediolateral oblique spot compression magnification mammogram demonstrates a small cluster of microcalcifications (arrows) that vary in size and shape. These were reported as new but "benign-appearing," and short-interval follow-up imaging was recommended. (b) Follow-up image obtained 13 months later demonstrates an increase in the number of calcifications, although motion blur degrades the image somewhat. Biopsy demonstrated high-grade comedo DCIS. Only homogeneous round and oval calcifications should be classified as probably benign, and interval change should prompt biopsy unless the calcifications are characteristically benign, such as milk-of-calcium.

View larger version (124K): [in a new window]   Figure 4a. (a) Bilateral mediolateral oblique views in a 58-year-old woman depict two oval masses (arrows) in the upper aspect of each breast that were new compared with prior studies. These were assessed as probably benign, and short-term follow-up imaging was recommended. (b) Bilateral mediolateral oblique views obtained 4 months later demonstrate marked interval progression. At biopsy, both lesions were invasive ductal carcinoma. Developing solid masses should not be placed into a short-term follow-up category. If an enlarging mass is not characteristic of a benign process such as a simple cyst, biopsy should be performed.

View larger version (106K): [in a new window]   Figure 4b. (a) Bilateral mediolateral oblique views in a 58-year-old woman depict two oval masses (arrows) in the upper aspect of each breast that were new compared with prior studies. These were assessed as probably benign, and short-term follow-up imaging was recommended. (b) Bilateral mediolateral oblique views obtained 4 months later demonstrate marked interval progression. At biopsy, both lesions were invasive ductal carcinoma. Developing solid masses should not be placed into a short-term follow-up category. If an enlarging mass is not characteristic of a benign process such as a simple cyst, biopsy should be performed.

View larger version (158K): [in a new window]   Figure 5a. (a) Focal compression mediolateral oblique mammogram of the left upper breast demonstrates asymmetric density and subtle architectural distortion (arrow). Diagnostic evaluation was limited to focal compression in the mediolateral oblique view, and the finding (described as "asymmetric density/architectural distortion") was attributed to superimposition. Six-month follow-up mammography was recommended to assess stability, even though the density had already increased from the prior study. (b) Spot compression magnification mammogram obtained 6 months later better demonstrates the architectural distortion. The lesion was confirmed with multiple projections, and directed US confirmed a suspicious mass. Biopsy demonstrated a 1.5-cm invasive ductal carcinoma. Developing densities should not be considered probably benign, since their interval change from prior studies precludes that assessment category and should prompt tissue diagnosis. Spot compression magnification may better image subtle architectural distortion because of its superior contrast and resolution.

View larger version (141K): [in a new window]   Figure 5b. (a) Focal compression mediolateral oblique mammogram of the left upper breast demonstrates asymmetric density and subtle architectural distortion (arrow). Diagnostic evaluation was limited to focal compression in the mediolateral oblique view, and the finding (described as "asymmetric density/architectural distortion") was attributed to superimposition. Six-month follow-up mammography was recommended to assess stability, even though the density had already increased from the prior study. (b) Spot compression magnification mammogram obtained 6 months later better demonstrates the architectural distortion. The lesion was confirmed with multiple projections, and directed US confirmed a suspicious mass. Biopsy demonstrated a 1.5-cm invasive ductal carcinoma. Developing densities should not be considered probably benign, since their interval change from prior studies precludes that assessment category and should prompt tissue diagnosis. Spot compression magnification may better image subtle architectural distortion because of its superior contrast and resolution.

View larger version (171K): [in a new window]   Figure 6a. (a) Right craniocaudal mammogram demonstrates an area of subtle architectural distortion (arrows). This was prospectively described as an asymmetric density for which 6-month follow-up was recommended. This lesion was followed up for 36 months and described repeatedly as a stable asymmetric density. (b) Right craniocaudal mammogram obtained 36 months after a demonstrates subtle architectural distortion that is unchanged. Biopsy, however, was recommended and demonstrated a low-grade invasive ductal adenocarcinoma. No spot compression or spot compression magnification images were obtained at the time initial images were interpreted, and follow-up was recommended. Architectural distortion, no matter how subtle, should not be classified as probably benign. Even stability, as demonstrated by this case, should not dissuade biopsy of architectural distortion.

View larger version (175K): [in a new window]   Figure 6b. (a) Right craniocaudal mammogram demonstrates an area of subtle architectural distortion (arrows). This was prospectively described as an asymmetric density for which 6-month follow-up was recommended. This lesion was followed up for 36 months and described repeatedly as a stable asymmetric density. (b) Right craniocaudal mammogram obtained 36 months after a demonstrates subtle architectural distortion that is unchanged. Biopsy, however, was recommended and demonstrated a low-grade invasive ductal adenocarcinoma. No spot compression or spot compression magnification images were obtained at the time initial images were interpreted, and follow-up was recommended. Architectural distortion, no matter how subtle, should not be classified as probably benign. Even stability, as demonstrated by this case, should not dissuade biopsy of architectural distortion.