Architectural Distortions Detected by DBT Alone With No Ultrasound Correlate and Nonmalignant Results on Core Needle Biopsy: Outcomes From an Imaging-Focused Management Strategy

BACKGROUND. Architectural distortions (ADs) detected on digital breast tomosynthesis (DBT) are more frequently associated with nonmalignant pathologies than those detected on digital mammography. OBJECTIVE. The purpose of this study was to evaluate outcomes of ADs detected by DBT alone with no ultrasound correlate and nonmalignant results on core needle biopsy (CNB) when adopting a management strategy selectively incorporating imaging surveillance. METHODS. This retrospective study included patients with ADs detected by DBT alone with no ultrasound correlate and nonmalignant results on stereotactic CNB with 12 vacuum-assisted 9-gauge cores from July 1, 2020, to December 31, 2023. ADs detected by DBT alone with no ultrasound correlate showing concordant benign pathology or radial scar without atypia on CNB were recommended to undergo 6- and 12-month diagnostic imaging follow-up before returning to annual screening, whereas those showing atypia (with or without radial scar) on CNB were recommended to undergo surgical excision; however, patients could electively undergo the alternative management option. Malignancy rates were assessed, considering ADs to be nonmalignant based on results of repeat CNB, surgical excision, or 12-month diagnostic imaging follow-up. RESULTS. The final sample included 106 patients (mean age, 58 years) with 109 ADs meeting selection criteria and that underwent repeat CNB, surgical excision, or 12 months of diagnostic imaging follow-up. The malignancy rate was 0% (0/58) for ADs showing benign pathology on CNB (49 with imaging surveillance, two with repeat CNB, seven with excision), 0% (0/36) for ADs showing radial scar without atypia on CNB (22 with imaging surveillance, 14 with excision), 10% (1/10) for ADs showing radial scar with atypia on CNB (all with excision), and 40% (2/5) for ADs showing atypia without radial scar on CNB (two with imaging surveillance, three with excision). Overall, the malignancy rate was 0% (0/94) versus 20% (3/15) in the absence versus presence, respectively, of atypia (with or without radial scar) on CNB. CONCLUSION. The malignancy rate was 0% for ADs without atypia, versus 20% for ADs with atypia, on CNB. CLINICAL IMPACT. Imaging surveillance may be a safe alternative to surgical excision for ADs detected by DBT alone with no ultrasound correlate showing benign pathology without atypia on CNB.