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Case 03



Don't dismiss recombined-only findings!

The left breast mass at 11:00 and right breast mass at 10:00 were both invasive ductal cancer, ER/PR+ HER2-, grade 1. The right breast mass at 9:00 was a smattering of benign pathologies, such as adenosis and usual ductal hyperplasia. Neither of the right breast findings were seen on the low-energy images. They only showed up as as masses on the recombined images. So how should we handle them?

Recombined-only findings can be cancer and should be worked up!

As of yet, there is not enough data to tell us how frequently these recombined-only findings are cancer. However, there is increasing anecdotal data suggesting that the probability of malignancy is high enough to warrant more imaging evaluation. Research data is also emerging confirming this. Further work-up can include: (1) additional attempts to find a correlate on low-energy images with spot compression views, rolled views, lateral view, etc, (2) comparison to priors to see if a low-energy correlate has been present on multiple priors to suggest long-term stability and benignity (3) targeted ultrasound to identify and further characterize the area -- as was done in this case, (4) or breast MRI. Rarely would follow-up imaging be the next recommended step. If benignity cannot be clearly delineated based on the imaging, then sampling should be performed. In this case, we saw the findings on ultrasound and therefore pursued ultrasound guided core biopsy.

Perry H, Phillips J, Dialani V, Slanetz PJ, et al. Contrast-Enhanced Mammography: A Systematic Guide to Interpretation and Reporting. AJR Am J Roentgenol. 2019 Jan;212(1):222-231.

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