3D mammography may shake ‘routine’ out of architectural distortion surgery

When counseling patients with architectural distortion on digital breast tomosynthesis (DBT) but no signs of malignancy on biopsy, mammographers should raise imaging alone as a sound option for surveillance.

So suggest breast radiology researchers at Massachusetts General Hospital who reviewed final diagnoses of 129 architectural distortions in 125 women imaged with digital 2D mammography as well as DBT.

All patients were seen at the authors’ institution, and all underwent surgical excision of lesions deemed nonmalignant at image-guided needle biopsy.

Publishing their findings in the July print edition of the American Journal of Roentgenology, Juan Villa-Camacho, MD, and Manisha Bahl, MD, MPH, report 10.2% of all lesions being upgraded from benign on imaging to malignant following surgery [1].  

However, of cases that had architectural distortion on imaging but no atypical cells at biopsy, only 2.2% were upgraded to malignant after excision.

For cases with both architectural distortion and atypia, the upgrade rate was 28.2%.

“These results suggest that imaging surveillance rather than surgery can be considered for architectural distortion on digital breast tomosynthesis yielding radial scar and other benign pathologies without atypia at biopsy,” the authors comment.

No Significant Associations Between Upgrades to Malignancies and Numerous Features of Interest

Other findings of interest as itemized by the authors:

  • At biopsy, 92 lesions (71.3%) were radial scars and 37 (28.7%) were other nonmalignant pathologies.
  • Of 66 radial scars without atypia at biopsy, one (1.5%) was upgraded to ductal carcinoma in situ (DCIS) at surgery and none to invasive cancer.
  • Of 24 benign pathologies without atypia at biopsy, one was considered discordant.
  • Of the 23 remaining concordant cases, one (4.3%) was upgraded to DCIS at surgery and none to invasive cancer.

Villa-Camacho and Bahl also report finding no significant associations between upgrades to malignancies and various features of interest.

The features, which spanned clinical as well as imaging variables, included age, personal or family breast cancer history, presentation by screening vs diagnostic mammography, breast density, associated mammographic findings, presence and size of ultrasound correlate and biopsy modality.

“Historically, surgery has been recommended for all cases of architectural distortion, including cases that are nonmalignant at biopsy,” the authors comment in their discussion. “Our results support the continuation of surgical consultation and excision for architectural distortion [only] on digital breast tomosynthesis with associated atypia.”

A Call for Multidisciplinary Medicine and Shared Decision-making

In accompanying commentary, Amie Lee, MD, of UC-San Francisco remarks that the Villa-Camacho and Bahl study:

highlights that the long-established approach of uniformly recommending surgical excision for all radial scars no longer applies in the era of DBT. Ultimately, the decision to excise requires a multidisciplinary approach and shared decision-making with patients.”

Lee cites recent literature showing a “very low upgrade risk for these lesions, leading to wide practice variation regarding whether these lesions require routine excision.”

She further points to current guidelines from the American Society of Breast Surgeons stating that most radial scars “should be excised, although imaging follow-up is reasonable” in certain scenarios [2].

All three researchers comment that, given the study’s retrospective and single-center design, large and prospective studies are needed to validate or challenge the present review’s findings and observations.

 

More Coverage of Breast Architectural Distortion:

Malignant architectural distortion ably diagnosed on breast imaging by human-AI combo

When does worrisome architectural distortion signal malignancy on mammography?

DBT detects more architectural distortion lesions than 2D mammography alone

New research can help radiologists manage architectural distortion identified via DBT exams

3D mammography detects more architectural distortions than 2D

Tomosynthesis trumps mammo alone for spotting architectural distortion

Find more breast imaging news 

Find more AI in radiology news

 

References:

  1. Juan Villa-Camacho and Manisha Bahl, “Management of Architectural Distortion on Digital Breast Tomosynthesis With Nonmalignant Pathology at Biopsy.” American Journal of Roentgenology, July 2022. DOI: https://doi.org/10.2214/AJR.21.27161
  2. Amie Y. Lee, “Architectural Distortion on Digital Breast Tomosynthesis—to Excise or Not to Excise?” American Journal of Roentgenology, July 2022. DOI: https://doi.org/10.2214/AJR.22.27517

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