Memenin Kitle Dışı Lezyonlarında Radyolojik Görüntüleme
Özet
Bu çalışma, memenin kitle dışı lezyonlarının (KDL) ultrasonografi (US), mamografi (MG) ve manyetik rezonans görüntüleme (MRG) yöntemleriyle değerlendirilmesini, tanısal standardizasyonunu ve ileri sonografik tekniklerin rolünü incelemektedir. Klasik kitle bulgusu vermeyen KDL'ler, normal parankimden iki planda ayrılan yapılar olup en sık benign (%46-90) karakter gösterse de malignite (%10-54) riski de barındırırlar. BI-RADS atlasında henüz net bir standardizasyonu bulunmayan bu lezyonların yanlış yorumlanması gereksiz biyopsilere veya gecikmiş tanılara yol açabilmektedir. Lezyonların dağılım paternleri, duktal ilişkileri, internal ekojeniteleri, mikrokalsifikasyon ve posterior akustik gölgelenme gibi eşlik eden gri skala bulguları malign-benign ayrımında kritiktir. Ayrıca konvansiyonel yöntemlere ek olarak uygulanan sonoelastografi (lezyon sertliği ölçümü) ve düşük akımlı damarları saptayan mikrovasküler görüntüleme gibi ileri sonografik teknikler, özellikle BI-RADS 4A kategorisindeki lezyonların spesifitesini belirgin şekilde artırarak tanısal doğruluğa katkı sağlamaktadır. Metinde benign fibrokistik değişiklikler, mastit ve yağ nekrozundan; malign potansiyeli belirsiz B3 lezyonlarına (radyal skar, papillomlar) ve in situ/invaziv karsinomlara (DKİS, İDK, İLK) kadar geniş bir histopatolojik spektrumun radyolojik yansımaları ve korelasyon gereklilikleri detaylandırılmıştır.
This study evaluates the assessment, diagnostic standardization, and the role of advanced sonographic techniques in non-mass lesions (NML) of the breast using ultrasonography (US), mammography (MG), and magnetic resonance imaging (MRI). NMLs, which do not exhibit typical mass findings but are distinguished from normal parenchyma in two projections, are mostly benign (46-90%) but carry a malignancy risk of 10-54%. Misinterpretation of these lesions, which lack a clear standardization in the BI-RADS atlas, can lead to unnecessary biopsies or missed diagnoses. Gray-scale findings such as distribution patterns, ductal relationships, internal echogenicity, microcalcifications, and posterior acoustic shadowing are critical for differentiating benign from malignant lesions. In addition to conventional methods, advanced sonographic techniques like sonoelastography (measuring lesion stiffness) and microvascular imaging (detecting low-velocity blood flow) significantly increase specificity, particularly in BI-RADS 4A lesions, thereby enhancing diagnostic accuracy. The text details the radiological manifestations and correlation requirements across a wide histopathological spectrum, ranging from benign fibrocystic changes, mastitis, and fat necrosis to B3 lesions of uncertain malignant potential (radial scar, papillomas) and in situ/invasive carcinomas (DCIS, IDC, ILC).
Referanslar
American College of Radiology, Breast Imaging and Reporting Data System, American College of Radiology, Reston, Va; 1992.
American College of Radiology. Breast imaging reporting and data system (BI-RADS). 4th ed. Reston, Va: American College of Radiology, 2003.
D’orsi S, Sickles EA, Mendelson EB, et al. Breast Imaging Reporting and Data System: ACR BI-RADS breast imaging atlas. 5th ed. Reston, Va: American College of Radiology, 2013.
Japan Association of Breast and Thyroid Sonology, 2004: Guideline for Breast Ultrasound-Management and Diagnosis, Tokyo, Japan: Nankodo, pp35-37, 53-60, 2004.
Uematsu T. Non-mass-like lesions on breast ultrasonography: a systematic review. Breast Cancer. 2012;19(4): 295-301.
Kim SJ, Park YM, Jung HK. Nonmass like lesions on breast sonography: comparison between benign and malignant lesions. Journal of Ultrasound and Medicine. 2014;33(3): 421–430.
Ko KH, Hsu HH, Yu JC, et al. Non-mass-like breast lesions at ultrasonography: feature analysis and BI-RADS assessment. European Journal of Radiology. 2015;84(1): 77-85.
Wang ZL, Li N, Li M, et al. Non-mass-like lesions on breast ultrasound: classification and correlation with histology. La Radiologica Medica. 2015;120(10): 905-910.
Park JW, Ko KH, Kim EK, et al. Non-mass breast lesions on ultrasound: final outcomes and predictors of malignancy. Acta Radiologica. 2017;58(9): 1054-1060.
Choe J, Chikarmane SA, Giess CS. Nonmass Findings at Breast US: Definition, Classifications, and Differential Diagnosis. Radiographics. 2020;40(2): 326-335.
Mann RM, Cho N, Moy L. Breast MRI: State of the Art. Radiology. 2019;292(3): 520-536.
Hooley RJ, Scoutt LM, Philptts LE. Breast ultrasonography: State of the art. Radiology. 2013;268: 642-659.
Buchberger W, Geiger-Gritsch S, Knapp R, et al. Combined screening with mammography and ultrasound in a population-based screening program. European Journal of Radiology. 2018;101: 24-29.
Ohuchi N, Suzuki A, Sobue T, et al. J-START Investigator Groups. Sensitivity and specificity of mammography and adjunctive ultrasonography to screen for breast cancer in the Japan Strategic Anti-Cancer Randomized Trial (J-START): a randomised controlled trial. Lancet. 2016;387 (10016): 341-348.
Sree SV. Breast imaging: A survey. World Journal of Clinical Oncology. 2011;2: 171.
Lee JM, Arao RF, Sprague BL, et al. Performance of Screening Ultrasonography as an Adjunct to Screening Mammography in Women Across the Spectrum of Breast Cancer Risk. JAMA Internal Medicine. 2019;179(5): 658–667.
Park KW, Park S, Shon I, et al. Non-mass lesions detected by breast US: stratification of cancer risk for clinical management. European Radiology. 2021;31(3): 1693-1706.
Ban K, Tsunoda H, Watanabe T, et al. Characteristics of ultrasonographic images of ductal carcinoma in situ with abnormalities of the ducts. Journal of Medical Ultrasound. 2020;47(1): 107-115.
Gunawardena DS, Burrows S, Taylor DB. Non-mass versus mass-like ultrasound patterns in ductal carcinoma in situ: is there an association with high-risk histology? Clinical Radiology. 2020;75(2): 140-147.
Stavros AT. Breast anatomy: the basis for understanding sonography Breast Ultrasound, Lippincott Williams & Wilkins, Philadelphia, PA; 2004.
Zhu YC, Zhang Y, Deng SH, et al. Diagnostic Performance of Superb Microvascular Imaging (SMI) Combined with Shear-Wave Elastography in Evaluating Breast Lesions. Medical Science Monitor. 2018;24: 5935-5942.
Zhang XY, Zhang L, Li N, et al. Vascular index measured by smart 3-D superb microvascular imaging can help to differentiate malignant and benign breast lesion. Cancer Management and Research. 2019;11: 5481-5487.
Lee EJ, Chang YW. Combination of Quantitative Parameters of Shear Wave Elastography and Superb Microvascular Imaging to Evaluate Breast Masses. Korean Journal of Radiology. 2020;21 (9): 1045-1054.
Zhong L, Wang C. Diagnostic accuracy of ultrasound superb microvascular imaging for breast tumor: a meta-analysis. Medical Ultrasonography. 2020;22(3): 313-318.
Zhang W, Xiao X, Xu X, et al. Non-Mass Breast Lesions on Ultrasound: Feature Exploration and Multimode Ultrasonic Diagnosis. Ultrasound in Medicine and Biology. 2018;44(8): 1703-1711.
Choi JS, Han BK, Ko EY, et al. Additional diagnostic value of shear-wave elastography and color Doppler US for evaluation of breast non-mass lesions detected at B-mode US. European Radiology. 2016;26(10): 3542-3549.
Li L, Zhou X, Zhao X, et al. B-Mode Ultrasound Combined with Color Doppler and Strain Elastography in the Diagnosis of Non-mass Breast Lesions: A Prospective Study. Ultrasound in Medicine and Biology. 2017;43(11): 2582-2590.
Hong S, Li W, Gao W, et al. Diagnostic performance of elastography for breast non-mass lesions: A systematic review and meta-analysis. European Journal of Radiology. 2021;144: 109991.
Sefidbakht S, Haseli S, Khalili N, et al. Can shear wave elastography be utilized as an additional tool for the assessment of non-mass breast lesions? The Ultrasound Journal. 2022;30(1): 44-51.
Park SY, Choi JS, Han BK, et al. Shear wave elastography in the diagnosis of breast non-mass lesions: factors associated with false negative and false positive results. European Radiology. 2017;27(9): 3788-3798.
Diao X, Zhan J, Chen L, et al. Role of Superb Microvascular Imaging in Differantiating Between Malignant and Benign Solid Breast Masses. Clinical Breast Cancer. 2020;20(6): e786-e793.
Liang M, Ou B, Wu J, et al. Combined use of strain elastography and superb microvascular imaging with grayscale ultrasound according to the BI-RADS classification for differentiating benign from malignant solid breast masses. Clinical Hemorheology and Microcirculation. 2020;74(4): 391–403.
Bakdik S, Arslan S, Oncu F, et al. Effectiveness of Superb Microvascular Imaging for the differentiation of intraductal breast lesions. Medical Ultrasonography. 2018;20(3): 306-312.
Tek C, Öztekin PS, Celepli P, et al. Using the Superb Microvascular Imaging Method in the Distinction of Intraductal Papilloma and Duct Ectasia With Secretion. Journal of Ultrasound and Medicine. 2021;40(2): 269-277.
Kayadibi Y, Bulut I, Aladag Kurt S, et al. The Role of Superb Microvascular Imaging (SMI) and Shearwave Elastography (SWE) in the Evaluation of Intraductal Papilloma-Like Lesions. Journal of Ultrasound and Medicine. 2021;9999: 1-14.
Adler DD, Carson PL, Rubin JM, et al. Doppler ultrasound color flow imaging in the study of breast cancer: Preliminary findings. Ultrasound in Medicine and Biology. 1990;16: 553‐559.
Chae EY, Yoon GY, Cha JH, et al. Added Value of the Vascular Index on Superb Microvascular Imaging for the Evaluation of Breast Masses: Comparison With Grayscale Ultrasound. Journal of Ultrasound in Medicine. 2021;40(4): 715-723.
Park AY, Seo BK, Cha SH, et al. An Innovative Ultrasound Technique for Evaluation of Tumor Vascularity in Breast Cancers: Superb Micro-Vascular Imaging. Journal of Breast Cancer. 2016;19(2): 210-213.
Ferris-James DM, Iuanow E, Mehta TS, et al. Imaging approaches to diagnosis and management of common ductal abnormalities. Radiographics. 2012;32(4): 1009-1030.
Royal College of Pathologists; NHS Cancer Screening Programmes. Guidelines for Non Operative Diagnostic Procedures and Reporting In Breast Cancer Screening. Publication No. 50 NHSBSP. Sheffield, UK 2001. https://www.gov.uk/government/publications/breast-screening-clinical-guidelines-for-screening-management.
Houssami N, Cheung MN, Dixon JM. Fibroadenoma of the breast. The Medical Journal of Australia. 2001;174: 185-188
Rakha EA, Lee AHS, Jenkins JA, et al. Characterization and outcome of breast needle core biopsy diagnoses of lesions of uncertain malignant potential (B3) in abnormalities detected by mammographic screening. The International Journal of Cancer. 2011;129: 1417–1424.
Dillon MF, McDermott EW, Hill AD, et al. Predictive value of breast lesions of “uncertain malignant potential” and “suspicious for malignancy” determined by needle core biopsy. Annals of Surgical Oncology. 2007;14: 704–711
Kennedy M, Masterson AV, Kerin M, et al. Pathology and clinical relevance of radial scars: a review. Journal of Clinical Pathology. 2003;56(10): 721-724.
Alleva DQ, Smetherman DH, Farr GH, et al. Radial scar of the breast: radiologic-pathologic correlation in 22 cases. Radiographics. 1999; 19 Spec No: S27-35; discussion S36-37.
Mulligan AM, O’Malley FP. Papillary lesions of the breast. Advances in Anatomic Pathology. 2007;14(2): 108-119.
Youk JH, Kim EK, Kim MJ. Atypical ductal hyperplasia diagnosed at sonographically guided 14-gauge core needle biopsy of breast mass. AJR American Journal of Roentgenology. 2009;192(4): 1135-1141.
Metovic J, Abate SO, Borella F, et al. The lobular neoplasia enigma: management and prognosis in a long follow-up case series. World Journal of Surgical Oncology. 2021;19: 80.
Bratthauer GL, Tavassoli FA. Lobular intraepithelial neoplasia: previously unexplored aspects assessed in 775 cases and their clinical implications. Virchows Archive. 2002;440: 134–138.
Tavassoli FA, Millis RR, Boecker W, Lakhani SR. Lobular neoplasia. In: Tavassoli FA, Devilee P, editors. Pathology and genetics of tumours of the breast and female genital organs. 3rd ed. Lyon: IARC Press; 2003. p. 60–62.
Dershaw DD, Abramson A, Kinne DW. Ductal carcinoma in situ: mammographic findings and clinical implications. Radiology. 1989;170(2,): 411-415.
Wang LC, Sullivan M, Du H, Feldman MI, Mendelson EB. US appearance of ductal carcinoma in situ. Radiographics. 2013;33(1): 213-228.
Lopez JK, Bassett LW. Invasive lobular carcinoma of the breast: spectrum of mammographic, US, and MR imaging findings. Radiographics. 2009;29(1): 165-176.
Lam WWM, Chu WCW, Tse GM, et al. Sonographic Appearance of Mucinous Carcinoma of the Breast. American Journal of Radiology. 2004;182: 1069-1074.
Puglisi F, Zuiani C, Bazzocchi M, et al. Role of mammography, ultrasound and large core biopsy in the diagnostic evaluation of papillary breast lesions. Oncology. 2003;65: 311-315.
Liberman L, Feng TL, Susnik B. MD Case 35: Intracystic Papillary Carcinoma with Invasion. Radiology. 2001;219: 781-784
Leddy R, Irshad A, Rumboldt T, et al. Review of metaplastic carcinoma of the breast: imaging findings and pathologic features. Journal of Clinical Imaging Science. 2012;2: 21.
Yang WT, Hennessy B, Broglio K, et al. Imaging differences in metaplastic and invasive ductal carcinomas of the breast. AJR American Journal of Roentgenology. 2007;189: 1288-92.
Kayadibi Y, Erginoz E, Cavus GH, et al. Primary neuroendocrine carcinomas of the breast and neuroendocrine differentiated breast cancers: Relationship between histopathological and radiological features. European Journal of Radiology. 2022;147: 110148
Giardini R, Piccolo C, Rilke F. Primary non-Hodgkin’s lymphomas of the female breast. Cancer. 1992;69: 725-735
Feder JM, de Paredes ES, Hogge JP, et al. Unusual breast lesions: radiologic-pathologic correlation. Radiographics. 1999; 19 Spec No: S11-26; quiz S260.
Ikeda DM, Helvie MA, Frank TS, et al. Paget disease of the nipple: radiologic-pathologic correlation. Radiology. 1993;189(1): 89-94.
Sawyer RH, Asbury DL. Mammographic appearances in Paget’s disease of the breast. Clinical Radiology. 1994;49(3): 185-188.
