Breast DDx - Differential Diagnoses
One of the most essential skills in radiology is being able to recognize a finding, categorize it, and list the possible diagnoses.
A lot of time is spent memorizing the differentials for an anterior mediastinal mass or a lytic bone lesion. Many times in breast imaging the differential can be simplified and narrowed down to "cancer" or "not cancer." Then a biopsy is used to sort it out. While this may be true, the concept of a differential diagnosis is still very relevant. Concordance - The Secret To Success
Concordance = determining whether the histologic results make sense with the imaging findings
It is essential to know the possible diagnostic outcomes for a particular imaging finding in order to determine biopsy concordance. If you biopsy an area of architectural distortion and the pathology comes back showing abundant fat and usual ductal hyperplasia, this is not concordant. Further intervention is required. Determining concordance is one of the most important (and often overlooked) steps in performing a breast biopsy.
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Architectural Distortion DDx:
Malignant Invasive Ductal Carcinoma Invasive Lobular Carcinoma Tubular Carcinoma DCIS Benign Radial Scar / Complex Sclerosing Lesion Sclerosing Adenosis Prior Surgery / Fat Necrosis Granular Cell Tumor or Fibromatosis - rare |
Developing Asymmetry DDX:
Malignant Invasive Ductal Carcinoma Invasive Lobular Carcinoma DCIS Benign PASH (Pseudoangiomatous Stromal Hyperplasia) Fibrocystic Changes / Cysts Hormone Therapy Effect Summation Artifact |
Linear Calcifications DDx:
Malignant DCIS Invasive Ductal Carcinoma Benign Vascular Calcifications Secretory Calcifications Calcified Sutures - rare Filariasis - rare |
Segmental Calcifications DDx:
Malignant DCIS Invasive Ductal Carcinoma with Intraductal Component Benign Secretory Calcifications Skin Calcifications Fibrocystic Changes / Milk of Calcium Sclerosing Adenosis Fat Necrosis |
Grouping of Calcifications DDx:
Malignant DCIS Invasive Ductal Carcinoma Atypical ADH (Atypical Ductal Hyperplasia) FEA (Flat Epithelial Atypia) ALH / Pleomorphic LCIS Benign Fibrocystic Changes / Milk of Calcium Artifact (anti-perspirant, ointment) Skin Calcifications Calcified Fibroadenoma Papilloma Sclerosing Adenosis Fat Necrosis |
Mass with Calcifications DDx:
Malignant Invasive Ductal Carcinoma DCIS Papillary Carcinoma Metaplastic Carcinoma - rare Benign Fibroadenoma Papilloma Vascular Lesions (e.g. Hemangioma) Fat Necrosis |
Bilateral Axillary Lymphadenopathy DDx:
Malignant Lymphoma CLL (Chronic Lymphocytic Leukemia) Axillary Node Metastases (Lung, Melanoma) - rare Benign Autoimmune Diseases (Rheumatoid, SLE, Sjogrens, etc) Acute or Chronic Infection (Mononucleosis, Cat-Scratch) Granulomatous Disease (Sarcoidosis, Tuberculosis) Diabetic Mastopathy Normal Variant (mild adenopathy) |
Unilateral Axillary Lymphadenopathy DDx:
Malignant Metastatic Breast Cancer Lymphoma / Leukemia Axillary Node Metastases (Lung, Melanoma) - rare Benign Acute Upper Extremity Infection Mastitis Cat-Scratch Disease Recent Vaccination in Ipsilateral Arm Recent Trauma to the Upper Extremity |
Circumscribed Hypoechoic Mass DDx:
Malignant Invasive Ductal Carcinoma (usually high grade) Mucinous Carcinoma Medullary Carcinoma Metastasis Benign Fibroadenoma Papilloma Lactating Adenoma Complicated Cyst Phyllodes Tumor PASH |
Hyperechoic Masses DDx:
Malignant Invasive Ductal Carcinoma Invasive Lobular Carcinoma Metastases to the Breast - rare Lymphoma - rare Benign Lipoma or Angiolipoma Fat Necrosis Hematoma Silicone Granuloma Sebaceous Cyst PASH Apocrine Metaplasia |
Breast Skin Lesions DDx:
Malignant Invasive Ductal Carcinoma - rare Melanoma Benign Sebaceous Cyst Epidermal Inclusion Cyst Mastitis/Breast Abscess Hematoma Fat Necrosis and/or Scar Radiation Changes Mole or Seborrheic Keratosis |
Cystic Breast Lesions DDx:
Simple Cyst Simple Cyst High Grade Invasive Ductal Carcinoma Metastatic Lymphadenopathy Mucinous Carcinoma Complicated Cyst Complicated Cyst Fibroadenoma Hematoma Fat Necrosis or Oil Cyst Galactocele Breast Abscess Complex Cystic Mass Invasive Ductal Carcinoma Papilloma Papillary Carcinoma Fibrocystic Changes with Apocrine Metaplasia |
T2 Hyperintense Masses DDx:
Malignant Mucinous Carcinoma Invasive Ductal Carcinoma Medullary or Metaplastic Carcinoma Benign Simple or Complicated Cyst Myxoid Fibroadenoma Apocrine Metaplasia Fat Necrosis Lymph Node Hematoma |
Nonmass Enhancement (NMLE) DDx:
Malignant DCIS Invasive Lobular Carcinoma Invasive Ductal Carcinoma Atypical Atypical Ductal Hyperplasia Lobular Neoplasia Benign Fibrocystic Changes Normal Background or Hormone Effect Radiation Change Apocrine Metaplasia PASH Papilloma |