Benign Lesions

Vanzi, Ermanno; Di Naro, Federica; Bellini, Chiara

doi:10.1007/978-3-319-94553-8_11

Ermanno Vanzi³,
Federica Di Naro³ &
Chiara Bellini³

446 Accesses

Abstract

Benign breast lesions deserve attention because of their high prevalence. Breast cancer is the most common malignancy in women in developed countries; however, the vast majority of lesions that occur in the breasts are benign. The majority of patients, who present with a clinical breast problem, usually have a benign lesion. Diagnosis of a benign disease of the breast is usually accomplished with mammography, ultrasound (US), magnetic resonance imaging (MRI) or needle biopsies, thereby eliminating the need for surgery [1–3].

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Benign Breast Diseases

Benign Lesions of the Breast

Benign Breast Pathology

1 Introduction

Benign breast lesions deserve attention because of their high prevalence. Breast cancer is the most common malignancy in women in developed countries; however, the vast majority of lesions that occur in the breasts are benign. Most of the patients who present with a clinical breast problem, usually have a benign lesion. Diagnosis of a benign disease of the breast is usually accomplished with mammography, ultrasound (US), magnetic resonance imaging (MRI) or needle biopsies, thereby eliminating the need for surgery [1,2,3].

Benign breast lesions have been comprehensively studied, and most of these lesions are not associated with an increased risk of breast cancer; therefore, unnecessary surgical procedures should be avoided [3,4,5,6,7]. It is very important for radiologists to recognize benign breast lesions and to distinguish them from both in situ and invasive cancer and, in certain cases, to assess a patient’s risk of developing breast cancer so that the most appropriate treatment modality is established in every case [8,9,10].

Contrast-enhanced digital mammography (CEDM), which uses an iodinated contrast agent that has preferential uptake in regions of increased vascularity, provides physiological information that complements the morphological information obtained through conventional mammography [11, 12].

Invasive carcinomas usually present as enhancing lesions on CEDM; however, this presentation is not specific, and there is a significant percentage of benign lesions that produces similar false-positive results on CEDM [12, 13]. Benign lesions usually present as a weak or medium enhancement, rather than the strong enhancement pattern that is a typical indicator of malignant transformation [14]. However, there is no reliable CEDM enhancement pattern that is helpful in defining false-positive lesions.

2 CEDM Benign Findings

Similarities between benign and malignant lesion characteristics on mammography and ultrasound are well known. Breast MRI has not managed to resolve the issues of lesion specificity; and even if the typical appearance of benign breast conditions is well established, there are cases where it is still extremely difficult to differentiate benign lesions from malignant tumours; CEDM is no exception to this rule. Ultrasound examination (US) is the usual supplemental imaging technique to evaluate enhancing breast lesions on CEDM. It is usually followed by an ultrasound-guided core biopsy whenever there is a suspicion of malignancy.

Accumulating evidence has shown that CEDM is emerging as a new technique for the early diagnosis of breast cancer with a diagnostic accuracy comparable to that of breast MRI [15].

CEDM has recently been introduced as an adjunct and a potential alternative to MRI with some advantages, such as lower costs, shorter acquisition times, easier availability and the absence of typical MRI contraindications such as claustrophobia or the presence of metallic implants and cardiac pacemakers [12, 15].

However, as with MRI, CEDM is associated with many false-positive findings, which are benign breast-enhancing lesions that, not only extend the length of the workup, but can also lead to additional imaging studies and increased patient anxiety. Additionally, these false-positive findings may lead to unnecessary biopsies and interventions [13, 14].

Attempts have been made to identify features of benign and malignant lesions by CEDM to reduce false-positive findings and thus improve specificity. Although there is still no evidence that the kinetics in CEDM is similar to that of breast MRI, based on our experience, the morphologic features and enhancement kinetics of breast lesions may be used as descriptive methods for reducing false-positive findings [11,12,13].

3 Benign Breast Lesions

3.1 Fibroadenoma

Fibroadenoma is the most common benign tumour of the breast and occurs in up to 25% of asymptomatic women [1]. It is usually a disease of the early reproductive life; the peak incidence is between the ages of 15 and 35 years. The lesion is a hormone-dependent neoplasm that persists during reproductive years, increases with pregnancy or with oestrogen therapy and decreases after menopause [8].

Although most frequently unilateral, multiple fibroadenomas occur bilaterally in 20% of cases [5].

Macroscopically, the lesion is a well-circumscribed firm mass usually <3 cm in diameter. If the tumour assumes massive proportions (>10 cm), more commonly observed in female adolescents, it is called “giant fibroadenoma” [5].

Microscopically, fibroadenomas consist of a proliferation of epithelial and mesenchymal elements.

Approximately 50% of fibroadenomas contain other proliferative changes of the breast, such as sclerosing adenosis, adenosis and duct epithelial hyperplasia. Fibroadenomas that contain these elements are called “complex fibroadenomas”. Simple fibroadenomas are not associated with any increased risk of breast cancer. However, women with complex fibroadenoma may have a slightly higher risk for subsequent cancer [16].

When a suspicious fibroadenoma is identified upon examination or imaging, it is recommended to have a percutaneous core biopsy for histologic confirmation, as ultrasound alone cannot differentiate between fibroadenoma and a phyllodes tumour [16].

If a biopsy-proven fibroadenoma is stable and asymptomatic, it can be observed with routine examination. If the fibroadenoma increases in size, surgical excision is recommended to rule out a malignant change or a phyllodes tumour [17].

3.1.1 Fibroadenoma Findings

Fibroadenoma is the most common sharply marginated breast mass among women in their teens, twenties and early thirties.

On mammography, fibroadenomas appear as well-defined round, oval or lobulated masses, with the most common pattern of calcification devolving into coarser popcorn-shaped features. Calcifications may also present as crushed stone-like calcifications, which make differentiation from malignancy more difficult.

US is usually the next step towards characterization of the lesion.

On US, a fibroadenoma appears as a well-circumscribed elliptic mass that is either hypoechoic or isoechoic and has uniform echogenicity.

The lesion is typically larger in the transverse than in the anteroposterior direction and has very well-demarcated margins. A fibroadenoma may have no effect on ultrasound transmission, or acoustic enhancement or shadowing may be observed in US images [18, 19].

On MRI, fibroadenomas are hypointense or isointense lesions on T1-weighted images, and they are hypointense or hyperintense on T2-weighted images. Septations occur in approximately half of fibroadenomas and have been reported to be a strong indicator of this diagnosis. With gadolinium, the majority of fibroadenomas are hyperintense, with slow initial contrast enhancement followed by a persistent delayed phase, but some have rapid enhancement and either a plateau or a washout phase [5, 18, 19].
In our experience with CEDM, fibroadenomas show a faint, homogeneous enhancement with well-defined margins, and a persistent enhancement is seen in the delayed phase. Non-enhancing internal septations, similar to those seen on MRI, may be observed (Figs. 11.1, 11.2, 11.3, 11.4, and 11.5).

3.2 Breast Cysts

Breast cysts are the most common non-proliferative breast disease and are seen in over one-third of women aged 35–50 years, with 20–25% having a palpable mass [5, 6].

Simple cysts are derived from the terminal duct lobular unit and are fluid-filled round or ovoid masses.

Ultrasonography is the preferred imaging modality for breast cysts, providing an accurate evaluation of cyst content and complexity. Ultrasonography allows for characterization into simple, complicated and complex cysts. Features that increase the likelihood of malignancy include a thickened cyst wall, thick septations, solid internal components and hyperechogenicity of the internal fluid.

Complex cysts are defined by ultrasound criteria as masses with the presence of intracystic solid components and thick walls or septa. Complex cysts have a relatively higher risk of malignancy ranging from 5 to 23% and should therefore be evaluated with a tissue biopsy [20].

3.2.1 Simple Cyst Findings

Simple cysts are the most common masses seen in the breast in young woman and result from dilatation and effacement of the terminal duct lobular unit.

They are benign and have no risk of malignancy. No intervention is necessary for simple cysts.

However, if they are large and cause pain, aspiration may be necessary for pain relief. If the fluid is clear, no investigation is needed; however, if the fluid is haemorrhagic, it should be sent for cytologic analysis [20].

On mammography, they typically show a circumscribed round, oval or lobulated mass with well-defined margins.
On US, ultrasonography is the preferred imaging modality for breast cysts, providing an accurate evaluation of cyst content and complexity. Ultrasonography allows for characterization as simple, complicated and complex cysts.

Simple cysts are well-circumscribed, anechoic, have a thin echogenic capsule, increased through transmission, have thin edge shadows and lack internal solid components.

On MRI, these cysts follow fluid signals in all sequences, are iso- or hypointense to the breast parenchyma on T1-weighted images and are very hyperintense on T2-weighted images and do not enhance after gadolinium; however, the periphery of the cyst may enhance if there is surrounding pericystic inflammation [6, 8].
In our experience with CEDM, the findings consist of round areas of radiolucency with regular margins in keeping with the absence of enhancement, with possible peripheral enhancement in recombined images, which is also called “rim enhancement”. The enhancement could also be described as “eclipse sign”, because it resembles a full solar eclipse (Figs. 11.6 and 11.7).

3.2.2 Complicated Cyst Findings

A complicated cyst is a cyst that contains low-level internal echoes or fluid-fluid or fluid-debris levels that include cell debris, proteins, cholesterol, blood and epithelial cells.

The risk of malignancy with complicated cysts is 0.2%, but they should be aspirated to confirm diagnosis after imaging [7, 8].

On mammography, these complicated cysts show the same characteristic findings of simple cysts.
On US, complicated cysts have most, but not all, of the ultrasonographic criteria of a simple cyst: they may have homogeneous internal echoes but lack solid components, thick walls or septa and do not demonstrate increased vascularity.
On MRI, a complicated cyst may have intermediate or high signals on T1-weighted images due to proteinaceous contents or blood products. Their appearance on T2-weighted images is variable depending on the cyst contents [17, 20, 21].
In our experience with CEDM, the findings are similar to those observed for simple cysts; complex cysts appear as focal areas of radiolucency with thick irregular peripheral enhancement also called “rim enhancement” (Fig. 11.8).

3.2.3 Complex Cyst Findings

To avoid confusion with a complicated cyst, the current preferred term for complex breast cysts is a combination of solid and cystic mass. Complex cysts have a relatively higher risk of malignancy, ranging from 5 to 23%, and therefore should be evaluated with tissue biopsy [20].

The cysts that fall in these categories are galactoceles, haematomas, fat necrosis, abscesses, necrotic tumours, papillary tumours, atypical ductal hyperplasia and ductal carcinoma in situ (DCIS).

On mammography, these cysts show the same characteristic findings as simple cysts.
On US, these cysts contain thick wall, thick septae or intracystic masses that are characteristic of complex breast cysts [20].
In our experience with CEDM, the findings are similar to those observed for simple cysts; complex cysts appear as focal areas of radiolucency with thick irregular peripheral enhancement also called “rim enhancement” (Fig. 11.9). Occasionally, we may also observe intracystic enhancement due to the associated solid components.

3.3 Fibrocystic Changes

Fibrocystic changes are the most frequently encountered benign breast findings and occur most often in women of reproductive age between 20 and 50 years. Patients often present with a history of bilateral, menstrual-related, tender and nodular breasts, most often localized to the upper outer quadrants [5,6,7, 10].

Exact pathogenesis in unclear but hormonal imbalance with oestrogen predominance seems to be a relevant factor in their development [7].

Fibrocystic changes have no single histologic definition. It includes several histopathological categories such as microcystic and macrocystic formations, hyperplasia of the ductal epithelium, apocrine metaplasia, papillomatosis, ductal ectasia, sclerosing adenosis and stromal fibrosis.

As a result of these indistinct clinical and pathological findings, some authors have even questioned the validity of referring to fibrocystic change as a disease or even the use of the term [7].

Given the importance of determining if a clinical “fibrocystic lesion” is a risk factor for the subsequent development of breast cancer, lesions are further characterized under the histologic classification system proposed by DuPont and Page as non-proliferative lesions, proliferative lesions without atypia and proliferative lesions with atypia [16, 22, 23].

Breast cancer risk for these benign lesions is then classified according to histology. There is no elevated risk in women with biopsy-proven non-proliferative lesions. Proliferative disease without atypia and with atypical ductal/lobular hyperplasia is associated with a small increased breast cancer risk ranging from 1.2 to 2.0% and 3.7 to 5.3%, respectively [19, 22, 23].

3.3.1 Fibrocystic Changes Findings

Fibrocystic changes are usually defined as cystic degeneration of the breast parenchyma associated or not associated with fibrosis, adenosis and ductal or lobular hyperplasia [20].

Generally, fibrocystic changes consist of palpable lumps in the breast, associated with breast pain or tenderness, that fluctuate with the menstrual cycle.

On mammography, findings associated with fibrocystic disease are asymmetrical densities, architectural distortions (sclerosing adenosis) and microcalcifications (adenosis, apocrine metaplasia, ductal hyperplasia) with opacities corresponding to cysts, focal fibrosis or nodular adenosis [18, 24, 25].
On ultrasound, fibrocystic change consists of cysts (anechogenic for simple cyst, or echogenic for complicated or complex cysts, or often clustered microcysts), scattered echogenic foci due to microcalcifications (associated or not associated with cysts), solid masses and discrete masses due to fibrosis (homogeneous/inhomogeneous ovoid mass or irregular mass with shadowing) [24, 25].
On MRI, fibrocystic disease demonstrates a wide spectrum of morphologic and kinetic features. Fibrocystic disease commonly occurs as a diffuse type of non-mass-like regional enhancing lesion, with a benign enhancement pattern. They may also present as a focal mass-type lesion with enhancement kinetics usually showing rapid up-slope mimicking a breast cancer [26].
In our experience with CEDM, findings of fibrocystic change are seen as areas of non-mass-like parenchymal enhancement, usually of regional distribution, without specific characteristics, similar to their appearance on MRI that requires a second-look ultrasound to discriminate between benign or suspicious lesions (Figs. 11.10, 11.11, 11.12, and 11.13).

3.4 Hamartoma

Breast hamartomas are benign lesions also known as fibroadenolipoma or adenolipoma. They are uncommon tumour-like masses that have varying amounts of glandular, adipose and fibrous tissue. They present as encapsulated painless masses found upon screening mammography. The classic mammographic finding is a circumscribed area consisting of a mixture of both glandular tissue and lipomatous elements surrounded by a thin translucent zone [3, 27].

Hamartomas do not have specific diagnostic features upon histology with the exception of a nodular distribution of fat tissue within a fibrotic stroma that extends between individual lobules [3, 27].

3.4.1 Hamartoma Findings

On mammography, hamartomas are typically seen as oval or round masses, inhomogeneous with radio-opaque and radiotransparent areas reflecting the presence of tissues that differ in density, well-defined by a thin radio-opaque pseudocapsule and surrounded by breast parenchyma displaced by the mass [27].

The mass typically resembles a “slice of salami” with a “breast within a breast” appearance.

On US, hamartomas appear as solid, well-defined, oval formations lying parallel to the skin plane. They are inhomogeneous with hypoechoic areas intermixed with hyperechoic band-like or nodular areas, reflecting the presence of adipose, epithelial and fibrous connective tissues. Because hamartomas resemble the normal breast tissue, it is sometimes difficult to delineate their margins [28,29,30,31].
On MRI, hamartomas may present heterogeneous signal intensity on T1- and T2-weighted sequences, reflecting the presence of glandular and adipose tissue components and a thin capsule. After the administration of contrast medium, hamartomas show a gradual, progressive enhancement with a type I kinetic curve [32].
In our experience with CEDM, similar to MRI, hamartomas demonstrate slow heterogeneous initial enhancement pattern with a persistent delayed phase on the recombined CEDM images (Fig. 11.14).

3.5 Intraductal Papilloma (Without Atypia)

Papillomas are hyperplastic epithelial lesions composed of a central fibrovascular core covered by epithelium. Papillomas may be central, involving larger subareolar ducts, and are usually solitary or peripheral papillomas that involve terminal duct lobular units and are usually multiple. The epithelial component of papillomas can harbour a spectrum of morphologic changes ranging from metaplasia to hyperplasia, atypical hyperplasia and in situ or invasive carcinoma. Given this risk of atypia and malignancy, the traditional recommendation after core needle biopsy of papilloma is surgical excision. However, there are recent reports concerning the potential safety of observation in patients diagnosed with solitary papilloma without atypia upon biopsy [33,34,35].

3.5.1 Intraductal Papilloma Findings

Intraductal papilloma is usually a retroareolar or central benign lesion, often associated with bloody or clear nipple discharge [23].

On mammography, when small and located in the retroareolar regions, intraductal papillomas can be occult due to the breast density. Larger lesions may appear as a round- or oval-shaped masses with well-circumscribed margins, associated with benign calcifications [36].
On galactography, intraductal papillomas appear as well-defined mural-based filling defects with smooth or lobulated contours [36].
On US, intraductal papillomas are seen as well-defined solid nodules or mural-based nodules within a dilated duct [36].
On MRI, intraductal papillomas are shown as enhancing nodules with or without intraductal components that may have high signal on T1-weighted images if the duct contains proteinaceous debris or haemorrhage. A round filling defect may be seen within the duct. Papillomas enhance avidly with gadolinium. The enhancement of these nodules may be uniform or irregular with either washout or plateau kinetics, making differentiation from invasive malignancies potentially difficult [36].
In our experience with CEDM, intraductal papillomas demonstrate peri- or retroareolar, ductal and homogeneous enhancement in the recombined images (Figs. 11.15 and 11.16).

3.6 Fat Necrosis

Fat necrosis is a benign non-suppurative inflammatory process of the adipose tissue. It is important to diagnose because it can often mimic breast carcinoma. Fat necrosis is most commonly the result of trauma or surgery to the breast [3].

Examination and imaging of fat necrosis may be concerning for malignancy due to dense palpable masses, erythema, skin retraction and skin thickening.

It is sometimes necessary to biopsy the lesion to confirm diagnosis, although with experience it is possible to delineate this diagnosis particularly when oil cysts are present.

Conservative management is recommended unless there is a serious cosmetic distortion of the breast, in which case surgery can be considered [37].

3.6.1 Fat Necrosis Findings

On mammography, fat necrosis can present as oil cysts x-ray transparency, coarse calcifications, focal asymmetries, microcalcifications or spiculated masses. The mass usually appears as a radiolucent mass with linear and curvilinear calcifications. Sometimes, the calcifications are of concern due to their shape and distribution: branching, rod-like, angular or pleomorphic-clustered calcifications are sometimes indistinguishable from those of malignancy.

Occasionally, the reparative fibrotic reactions may replace all of the radiolucent necrotic fat, resulting in the appearance of a focal asymmetric density, a focal dense mass or an irregular spiculated mass upon mammography [38].

On US, fat necrosis may present as a solid mass or a complex mass with echogenic nodules, a complex mass with echogenic bands, an anechoic mass with posterior acoustic enhancement, an anechoic mass with shadowing or an isoechoic mass. The margins range from well-circumscribed to indistinct or spiculated.
On MRI, fat necrosis usually shows signal of heterogeneous intensity on T1weighted sequences, which may be due to its haemorrhagic and inflammatory content. Calcifications are sometimes seen on MRI as areas of absence of signal. Fibrosis may appear as high, intermediate or low signal on T1weighted images. Post-gadolinium, fat necrosis can enhance and be focal or diffuse and homogeneous or heterogeneous. Enhancement depends on the intensity of the inflammatory process. The fat suppression sequence is important for identifying enhancing breast cancers or enhancing regions of fat necrosis because the high signal of fat interferes with the detection of enhancing lesions. Enhancement patterns may vary from slow, gradual enhancement to rapid enhancement [38].
In our experience with CEDM, similar to MRI, fat necrosis appears as focal or diffuse areas of enhancement, with either a homogeneous or heterogeneous pattern of enhancement on CEDM recombined images (Figs. 11.17, 11.18 and 11.19).

Conclusion

Although the introduction of CEDM has increased both the sensitivity and specificity of the detection of breast cancer over digital mammography and ultrasonography, the specificity of CEDM, similar to breast MRI, is still limited because some benign lesions have features that are indistinguishable from cancers [39,40,41].

The specificity of CEDM can be improved by combining morphological and dynamic characteristics and correlating CEDM presentation with clinical, mammographic and ultrasonographic features, although in our experience biopsy is usually necessary for further differentiation in many of these benign enhancing findings [42].

References

Guray M, Sahin A. Benign breast diseases: classification, diagnosis, and management. Oncologist. 2006;11(5):435–49.
Article Google Scholar
Putti TC, Pinder SE, et al. Breast pathology practice: most common problems in a consultation service. Histopathology. 2005;47:445–57.
Article CAS Google Scholar
Miltenburg DM, Speigths VO Jr. Benign breast disease. Obstet Gynecol Clin North Am. 2008;35:285–300.
Article Google Scholar
Neal L, Tortorelli CL, et al. Clinician’s guide to imaging and pathologic findings in benign breast disease. Mayo Clin Proc. 2010;85:274–9.
Article Google Scholar
Pearlman MD, Griffin JL. Benign breast disease. Obstet Gynecol. 2010;116:747–58.
Article Google Scholar
Santen RJ, Mansel R. Benign breast disorders. N Engl J Med. 2005;353:275–85.
Article CAS Google Scholar
Goehring C, Morabia A. Epidemiol Rev. 1997;19:310–27.
Article CAS Google Scholar
Runruang B, Kelleym J. Benign breast diseases: epidemiology, evaluation and management. Clin Obstet Gynecol. 2011;54:110–24.
Article Google Scholar
Hartmann LC, Sellers TA, et al. Benign breast disease and the risk of breast cancer. N Engl J Med. 2005;353:229–37.
Article CAS Google Scholar
Bartow SA, Pathak DR, Black WC, et al. Prevalence of benign, atypical and malignant breast lesions in populations at different risk for breast cancer. A forensic autopsy study. Cancer. 1987;60:2751–60.
Article CAS Google Scholar
Smith A. The principles of contrast mammography. Info@hologic.com.
Google Scholar
Lobbes MB, Smidt ML, et al. Contrast enhanced mammography: techniques, current results, and potential indications. Clin Radiol. 2013;68:935–44.
Article CAS Google Scholar
Diekmann F, Freyer M, et al. Evaluation of contrast enhanced digital mammography. Eur J Radiol. 2011;78:112–21.
Article Google Scholar
Kamal R, Helal M, et al. Can we apply the MRI BI-RADS lexicon morphology descriptors on contrast-enhanced spectral mammography? Br J Radiol. 2016;89(1064):20160157.
Article Google Scholar
Jochelson MS, Dershaw DD, Sung JS, et al. Bilateral contrast enhanced dual-energy digital mammography: feasibility and comparison with conventional digital mammography and MRI imaging in women with known breast carcinoma. Radiology. 2013;266:743–51.
Article Google Scholar
Dupont WD, Page DL. Risk factors for breast cancer risk associated with proliferative breast disease and atypical hyperplasia. Cancer. 1993;71:1258–65.
Article CAS Google Scholar
Orr B, Kelley JL III. Benign breast diseases: evaluation and management. Clinical Obstet Gynecol. 2016;59(4):710–26.
Article Google Scholar
Goel NB, Knight TE, et al. Fibrous lesions of the breast: imaging-pathologic correlation. Radiographics. 2005;25:1547–59.
Article Google Scholar
Dupont WD, Dl P, et al. Long term risk of breast cancer in women with fibroadenoma. N Engl J Med. 1994;331:10–5.
Article CAS Google Scholar
Houssami N, Irwig L, Ung O. Review of complex breast cysts: implications for cancer detection and clinical practice. ANZ J Surg. 2005;75:1080–5.
Article Google Scholar
Venta LA, Kim JP, Pelloski CE, et al. Management of complex breast cysts. AJR Am J Roentgenol. 1999;173:1331–6.
Article CAS Google Scholar
Jensen RA, Page DL, Dupont WD, et al. Invasive breast cancer risk in women with sclerosing adenosis. Cancer. 1989;64:1977–83.
Article CAS Google Scholar
London SJ, Connolly JL, Schnitt SJ, et al. A prospective study of benign breast disease and the risk of breast cancer. JAMA. 1992;267:941–4.
Article CAS Google Scholar
Hines N, Slanetz PJ, et al. Cystic masses of the breast. AJR. 2010;194:W122–33.
Article Google Scholar
Chen J, Nalcioglu O, et al. Fibrocystic change of the breast presenting as a focal lesion mimicking breast cancer in MR imaging. J Magn Reson Imaging. 2008;28(6):1499–505.
Article Google Scholar
Chen J, Liu H, et al. MR imaging features of fibrocystic change of the breast. Magn Reson Imaging. 2008;26(9):1207–14.
Article Google Scholar
Tse GM, Law BK, et al. Hamartoma of the breast: a clinical pathological review. J Clin Pathol. 2002;55:951–4.
Article CAS Google Scholar
Linda A, Zuiani C, et al. The wide spectrum of hyperechoic lesions of the breast. Clin Radiol. 2011;66:559–65.
Article CAS Google Scholar
Linda A, Zuini C, Lorenzon M, et al. Hyperechoic lesions of the breast: not always benign. AJR Am J Roentgenol. 2011;196:1219–24.
Article Google Scholar
Adrada B, Wu Y, Yang W. Hyperechoic lesions of the breast: radiologic-histopathologic correlation. AJR Am J Roentgenol. 2013;200:W518–30.
Article Google Scholar
Presazzi A, Di Giulio G, et al. Breast hamartoma: ultrasound, elastosonographic, and mammographic features. Mini pictorial essay. J Ultrasound. 2015;18:373–7.
Article CAS Google Scholar
Knogler T, Homolka P, et al. Application of BI-RADS descriptors in contrast enhanced dual-energy mammography: comparison with MRI. Breast Care. 2017;12:212–6.
Article Google Scholar
Tuffarelli M, Pellegrini A, et al. Positive predictive value of brast lesions of uncertain malignant potential (B3): Can we identify high risk patients? The value of a multidisciplinary team and implications in the surgical treatment. Surg Oncol. 2016;25:119–22.
Article Google Scholar
Rakha EA, Ho BC, et al. Outcome of breast lesions diagnosed as lesion of uncertain malignant potential (B3) or suspicious of malignancy (B4) on needle core biopsy, including detaile review of epithelial atypia. Histopathology. 2011;56:626–32.
Article Google Scholar
Rageth CJ, O’Flynn EAM, et al. First International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Breast Cancer Res Treat. 2016;159:203–2013.
Article Google Scholar
Eiada R, Chong J, et al. Papillary lesions of the breast: MRI, ultrasound, and mammographic appearances. AJR Am J Roentgenol. 2012;198:264–71.
Article Google Scholar
Tan PH, Lai LM, et al. Fat necrosis of the breast: a review. Breast. 2006;15:313–8.
Article CAS Google Scholar
Taboada J, Stephens T, et al. The many faces of fat necrosis in the breast. AJR Am J Roentgenol. 2009;192:815–25.
Article Google Scholar
Dromain C, Thibault F, Diekmann F, et al. Dual energy contrast-enhanced digital mammography: initial clinical result of a multireader, multicase study. Breast cancer Res. 2012;14:R94.
Article Google Scholar
Luczynka E, Heinze-Paluchowska S, et al. Contrast enhanced spectral mammography: comparison with conventional mammography and histopathology in 152 women. Korean J Radiol. 2014;15:689–96.
Article Google Scholar
Luczynka E, Niemiec J, et al. Degree of enhancement on contrast enhanced spectral mammography (CESM) and lesion type on mammography (MG): comparison based on histological results. Med Sci Monit. 2016;22:3886–93.
Article Google Scholar
Covington MF, Pizzitola VJ, et al. The future of contrast enhanced mammography. AJR Am J Roentgenol. 2018;210:1–9.
Article Google Scholar

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Diagnostic Senology Unit, Department of Radiology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
Ermanno Vanzi, Federica Di Naro & Chiara Bellini

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Ermanno Vanzi
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Federica Di Naro
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Diagnostic Senology Unit, Department of Radiology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
Jacopo Nori
Department of Radiology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
Maninderpal Kaur

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Vanzi, E., Di Naro, F., Bellini, C. (2018). Benign Lesions. In: Nori, J., Kaur, M. (eds) Contrast-Enhanced Digital Mammography (CEDM). Springer, Cham. https://doi.org/10.1007/978-3-319-94553-8_11

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DOI: https://doi.org/10.1007/978-3-319-94553-8_11
Published: 26 September 2018
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Benign Lesions

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