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Probably Benign Lesions
Wendie A. Berg, MD, PhD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Diagnostic Checklist

          TERMINOLOGY

          • Synonyms

            • Breast Imaging Reporting and Data System (BI-RADS) 3
          • Definitions

            • Specific lesion types with ≤ 2.0% risk of malignancy but > 0.2% risk of typically benign finding (BI-RADS 2)
            • Short-interval follow-up acceptable alternative to biopsy
              • Surveillance usually performed at 6 months, 12 months, and 24 months if stable at each follow-up
              • If lesion ↓ ≥ 20% in diameter (or resolves) at any follow-up, downgrade to BI-RADS 2 (or 1)
            • Those few cancers identified during surveillance should have prognosis = screen-detected cancers
            • Minimal cancer = invasive cancer ≤ 10 mm in size or DCIS

          IMAGING

          • General Features

            • Mammographic Findings

              • Ultrasonographic Findings

                • MR Findings

                  • Imaging Recommendations

                    • Image-Guided Biopsy

                      • Nuclear Medicine Findings

                        DIFFERENTIAL DIAGNOSIS

                          CLINICAL ISSUES

                          • Presentation

                            • Natural History & Prognosis

                              DIAGNOSTIC CHECKLIST

                              • Consider

                                • Image Interpretation Pearls

                                  Selected References

                                  1. Grimm et al: Solitary, Well-Circumscribed, T2 Hyperintense Masses on MRI Have Very Low Malignancy Rates. Journal of Breast Imaging, 2019, 1–6 doi:10.1093/jbi/wby014
                                  2. Grimm LJ et al: Patient perceptions of breast cancer risk in imaging-detected low-risk scenarios and thresholds for desired intervention: a multi-institution survey. J Am Coll Radiol. 15(6):911-9, 2018
                                  3. Guo Y et al: Retroareolar masses and intraductal abnormalities detected on screening ultrasound: can biopsy be avoided? Br J Radiol. 20170816, 2018
                                  4. Ha SM et al: Growing BI-RADS category 3 lesions on follow-up breast ultrasound: malignancy rates and worrisome features. Br J Radiol. 91(1087):20170787, 2018
                                  5. Moon HJ et al: Follow-up interval for probably benign breast lesions on screening ultrasound in women at average risk for breast cancer with dense breasts. Acta Radiol. 59(9):1045-50, 2018
                                  6. Grimm LJ et al: Suspicious breast calcifications undergoing stereotactic biopsy in women ages 70 and over: breast cancer incidence by BI-RADS descriptors. Eur Radiol. 27(6):2275-81, 2017
                                  7. Marcon M et al: First ultrasound diagnosis of BI-RADS 3 lesions in young patients: can 6-months follow-up be sufficient to assess stability? Eur J Radiol. 89:226-33, 2017
                                  8. Sprague BL et al: National performance benchmarks for modern diagnostic digital mammography: update from the Breast Cancer Surveillance Consortium. Radiology. 283(1):59-69, 2017
                                  9. Benndorf M et al: A history of breast cancer and older age allow risk stratification of mammographic BI-RADS 3 ratings in the diagnostic setting. Clin Imaging. 40(2):200-4, 2016
                                  10. Chae EY et al: Reassessment and follow-up results of BI-RADS category 3 lesions detected on screening breast ultrasound. AJR Am J Roentgenol. 206(3):666-72, 2016
                                  11. Monticciolo DL et al: Six-month short-interval imaging follow-up for benign concordant core needle biopsy of the breast: outcomes in 1444 cases with long-term follow-up. AJR Am J Roentgenol. 1-6, 2016
                                  12. Grimm LJ et al: Frequency of malignancy and imaging characteristics of probably benign lesions seen at breast MRI. AJR Am J Roentgenol. 205(2):442-7, 2015
                                  13. Barr RG et al: Probably benign lesions at screening breast US in a population with elevated risk: prevalence and rate of malignancy in the ACRIN 6666 trial. Radiology. 269(3):701-12, 2013
                                  14. Barr RG et al: The utility of the "bull's-eye" artifact on breast elasticity imaging in reducing breast lesion biopsy rate. Ultrasound Q. 2011 Sep;27(3):151-5. Erratum in: Ultrasound Q. 28(1):54, 2012
                                  15. Berg WA et al: Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 307(13):1394-404, 2012
                                  16. Berg WA et al: Shear-wave elastography improves the specificity of breast US: the BE1 multinational study of 939 masses. Radiology. 262(2):435-49, 2012
                                  17. Giess CS et al: Risk of malignancy in palpable solid breast masses considered probably benign or low suspicion: implications for management. J Ultrasound Med. 31(12):1943-9, 2012
                                  18. Hooley RJ et al: Screening US in patients with mammographically dense breasts: initial experience with Connecticut Public Act 09-41. Radiology. 265(1):59-69, 2012
                                  19. Noroozian M et al: Digital breast tomosynthesis is comparable to mammographic spot views for mass characterization. Radiology. 262(1):61-8, 2012
                                  20. Tagliafico A et al: One-to-one comparison between digital spot compression view and digital breast tomosynthesis. Eur Radiol. 22(3):539-44, 2012
                                  21. Yoon JH et al: Is US-guided core needle biopsy (CNB) enough in probably benign nodules with interval growth? Ultraschall Med. 33(7):E145-50, 2012
                                  22. Baum JK et al: Use of BI-RADS 3-probably benign category in the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial. Radiology. 260(1):61-7, 2011
                                  23. Narayanan D et al: Interpretation of positron emission mammography: feature analysis and rates of malignancy. AJR Am J Roentgenol. 196(4):956-70, 2011
                                  24. Salkowski LR et al: Utility of 6-month follow-up imaging after a concordant benign breast biopsy result. Radiology. 258(2):380-7, 2011
                                  25. Berg WA et al: Cystic breast masses and the ACRIN 6666 experience. Radiol Clin North Am. 48(5):931-87, 2010
                                  26. Brenner RJ: Short-term follow-up recommendations after preoperative breast MR assessment for breast cancer diagnosis: are we lacking a rational basis? Radiology. 257(1):18-21, 2010
                                  27. Loving VA et al: Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications. AJR Am J Roentgenol. 195(6):1472-7, 2010
                                  28. Eby PR et al: Characteristics of probably benign breast MRI lesions. AJR Am J Roentgenol. 193(3):861-7, 2009
                                  29. Harvey JA et al: Short-term follow-up of palpable breast lesions with benign imaging features: evaluation of 375 lesions in 320 women. AJR Am J Roentgenol. 193(6):1723-30, 2009
                                  30. Shin JH et al: Probably benign breast masses diagnosed by sonography: is there a difference in the cancer rate according to palpability? AJR Am J Roentgenol. 192(4):W187-91, 2009
                                  31. Kim EK et al: Clinical application of the BI-RADS final assessment to breast sonography in conjunction with mammography. AJR Am J Roentgenol. 190(5):1209-15, 2008
                                  32. Kim SJ et al: Application of sonographic BI-RADS to synchronous breast nodules detected in patients with breast cancer. AJR Am J Roentgenol. 191(3):653-8, 2008
                                  33. Raza S et al: BI-RADS 3, 4, and 5 lesions: value of US in management--follow-up and outcome. Radiology. 248(3):773-81, 2008
                                  34. Graf O et al: Probably benign breast masses at US: is follow-up an acceptable alternative to biopsy? Radiology. 244(1):87-93, 2007
                                  35. Leung JW et al: The probably benign assessment. Radiol Clin North Am. 45(5):773-89, vi, 2007
                                  36. Liberman L et al: Does size matter? Positive predictive value of MRI-detected breast lesions as a function of lesion size. AJR Am J Roentgenol. 186(2):426-30, 2006
                                  37. Rosenberg RD et al: Performance benchmarks for screening mammography. Radiology. 241(1):55-66, 2006
                                  38. Kerlikowske K et al: Breast cancer yield for screening mammographic examinations with recommendation for short-interval follow-up. Radiology. 234(3):684-92, 2005
                                  39. Sickles EA et al: Performance benchmarks for diagnostic mammography. Radiology. 235(3):775-90, 2005
                                  40. Graf O et al: Follow-up of palpable circumscribed noncalcified solid breast masses at mammography and US: can biopsy be averted? Radiology. 233(3):850-6, 2004
                                  41. Gordon PB et al: Solid breast masses diagnosed as fibroadenoma at fine-needle aspiration biopsy: acceptable rates of growth at long-term follow-up. Radiology. 229(1):233-8, 2003
                                  42. Varas X et al: Revisiting the mammographic follow-up of BI-RADS category 3 lesions. AJR Am J Roentgenol. 179(3):691-5, 2002
                                  43. Vizcaíno I et al: Short-term follow-up results in 795 nonpalpable probably benign lesions detected at screening mammography. Radiology. 219(2):475-83, 2001
                                  44. Leung JW et al: Multiple bilateral masses detected on screening mammography: assessment of need for recall imaging. AJR Am J Roentgenol. 175(1):23-9, 2000
                                  45. Sickles EA: Management of probably benign breast lesions. Radiol Clin North Am. 33(6):1123-30, 1995
                                  46. Sickles EA: Nonpalpable, circumscribed, noncalcified solid breast masses: likelihood of malignancy based on lesion size and age of patient. Radiology. 192(2):439-42, 1994
                                  47. Sickles EA: Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases. Radiology. 179(2):463-8, 1991
                                  Related Anatomy
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                                  Related Differential Diagnoses
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                                  References
                                  Tables

                                  Tables

                                  KEY FACTS

                                  • Terminology

                                    • Imaging

                                      • Top Differential Diagnoses

                                        • Diagnostic Checklist

                                          TERMINOLOGY

                                          • Synonyms

                                            • Breast Imaging Reporting and Data System (BI-RADS) 3
                                          • Definitions

                                            • Specific lesion types with ≤ 2.0% risk of malignancy but > 0.2% risk of typically benign finding (BI-RADS 2)
                                            • Short-interval follow-up acceptable alternative to biopsy
                                              • Surveillance usually performed at 6 months, 12 months, and 24 months if stable at each follow-up
                                              • If lesion ↓ ≥ 20% in diameter (or resolves) at any follow-up, downgrade to BI-RADS 2 (or 1)
                                            • Those few cancers identified during surveillance should have prognosis = screen-detected cancers
                                            • Minimal cancer = invasive cancer ≤ 10 mm in size or DCIS

                                          IMAGING

                                          • General Features

                                            • Mammographic Findings

                                              • Ultrasonographic Findings

                                                • MR Findings

                                                  • Imaging Recommendations

                                                    • Image-Guided Biopsy

                                                      • Nuclear Medicine Findings

                                                        DIFFERENTIAL DIAGNOSIS

                                                          CLINICAL ISSUES

                                                          • Presentation

                                                            • Natural History & Prognosis

                                                              DIAGNOSTIC CHECKLIST

                                                              • Consider

                                                                • Image Interpretation Pearls

                                                                  Selected References

                                                                  1. Grimm et al: Solitary, Well-Circumscribed, T2 Hyperintense Masses on MRI Have Very Low Malignancy Rates. Journal of Breast Imaging, 2019, 1–6 doi:10.1093/jbi/wby014
                                                                  2. Grimm LJ et al: Patient perceptions of breast cancer risk in imaging-detected low-risk scenarios and thresholds for desired intervention: a multi-institution survey. J Am Coll Radiol. 15(6):911-9, 2018
                                                                  3. Guo Y et al: Retroareolar masses and intraductal abnormalities detected on screening ultrasound: can biopsy be avoided? Br J Radiol. 20170816, 2018
                                                                  4. Ha SM et al: Growing BI-RADS category 3 lesions on follow-up breast ultrasound: malignancy rates and worrisome features. Br J Radiol. 91(1087):20170787, 2018
                                                                  5. Moon HJ et al: Follow-up interval for probably benign breast lesions on screening ultrasound in women at average risk for breast cancer with dense breasts. Acta Radiol. 59(9):1045-50, 2018
                                                                  6. Grimm LJ et al: Suspicious breast calcifications undergoing stereotactic biopsy in women ages 70 and over: breast cancer incidence by BI-RADS descriptors. Eur Radiol. 27(6):2275-81, 2017
                                                                  7. Marcon M et al: First ultrasound diagnosis of BI-RADS 3 lesions in young patients: can 6-months follow-up be sufficient to assess stability? Eur J Radiol. 89:226-33, 2017
                                                                  8. Sprague BL et al: National performance benchmarks for modern diagnostic digital mammography: update from the Breast Cancer Surveillance Consortium. Radiology. 283(1):59-69, 2017
                                                                  9. Benndorf M et al: A history of breast cancer and older age allow risk stratification of mammographic BI-RADS 3 ratings in the diagnostic setting. Clin Imaging. 40(2):200-4, 2016
                                                                  10. Chae EY et al: Reassessment and follow-up results of BI-RADS category 3 lesions detected on screening breast ultrasound. AJR Am J Roentgenol. 206(3):666-72, 2016
                                                                  11. Monticciolo DL et al: Six-month short-interval imaging follow-up for benign concordant core needle biopsy of the breast: outcomes in 1444 cases with long-term follow-up. AJR Am J Roentgenol. 1-6, 2016
                                                                  12. Grimm LJ et al: Frequency of malignancy and imaging characteristics of probably benign lesions seen at breast MRI. AJR Am J Roentgenol. 205(2):442-7, 2015
                                                                  13. Barr RG et al: Probably benign lesions at screening breast US in a population with elevated risk: prevalence and rate of malignancy in the ACRIN 6666 trial. Radiology. 269(3):701-12, 2013
                                                                  14. Barr RG et al: The utility of the "bull's-eye" artifact on breast elasticity imaging in reducing breast lesion biopsy rate. Ultrasound Q. 2011 Sep;27(3):151-5. Erratum in: Ultrasound Q. 28(1):54, 2012
                                                                  15. Berg WA et al: Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 307(13):1394-404, 2012
                                                                  16. Berg WA et al: Shear-wave elastography improves the specificity of breast US: the BE1 multinational study of 939 masses. Radiology. 262(2):435-49, 2012
                                                                  17. Giess CS et al: Risk of malignancy in palpable solid breast masses considered probably benign or low suspicion: implications for management. J Ultrasound Med. 31(12):1943-9, 2012
                                                                  18. Hooley RJ et al: Screening US in patients with mammographically dense breasts: initial experience with Connecticut Public Act 09-41. Radiology. 265(1):59-69, 2012
                                                                  19. Noroozian M et al: Digital breast tomosynthesis is comparable to mammographic spot views for mass characterization. Radiology. 262(1):61-8, 2012
                                                                  20. Tagliafico A et al: One-to-one comparison between digital spot compression view and digital breast tomosynthesis. Eur Radiol. 22(3):539-44, 2012
                                                                  21. Yoon JH et al: Is US-guided core needle biopsy (CNB) enough in probably benign nodules with interval growth? Ultraschall Med. 33(7):E145-50, 2012
                                                                  22. Baum JK et al: Use of BI-RADS 3-probably benign category in the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial. Radiology. 260(1):61-7, 2011
                                                                  23. Narayanan D et al: Interpretation of positron emission mammography: feature analysis and rates of malignancy. AJR Am J Roentgenol. 196(4):956-70, 2011
                                                                  24. Salkowski LR et al: Utility of 6-month follow-up imaging after a concordant benign breast biopsy result. Radiology. 258(2):380-7, 2011
                                                                  25. Berg WA et al: Cystic breast masses and the ACRIN 6666 experience. Radiol Clin North Am. 48(5):931-87, 2010
                                                                  26. Brenner RJ: Short-term follow-up recommendations after preoperative breast MR assessment for breast cancer diagnosis: are we lacking a rational basis? Radiology. 257(1):18-21, 2010
                                                                  27. Loving VA et al: Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications. AJR Am J Roentgenol. 195(6):1472-7, 2010
                                                                  28. Eby PR et al: Characteristics of probably benign breast MRI lesions. AJR Am J Roentgenol. 193(3):861-7, 2009
                                                                  29. Harvey JA et al: Short-term follow-up of palpable breast lesions with benign imaging features: evaluation of 375 lesions in 320 women. AJR Am J Roentgenol. 193(6):1723-30, 2009
                                                                  30. Shin JH et al: Probably benign breast masses diagnosed by sonography: is there a difference in the cancer rate according to palpability? AJR Am J Roentgenol. 192(4):W187-91, 2009
                                                                  31. Kim EK et al: Clinical application of the BI-RADS final assessment to breast sonography in conjunction with mammography. AJR Am J Roentgenol. 190(5):1209-15, 2008
                                                                  32. Kim SJ et al: Application of sonographic BI-RADS to synchronous breast nodules detected in patients with breast cancer. AJR Am J Roentgenol. 191(3):653-8, 2008
                                                                  33. Raza S et al: BI-RADS 3, 4, and 5 lesions: value of US in management--follow-up and outcome. Radiology. 248(3):773-81, 2008
                                                                  34. Graf O et al: Probably benign breast masses at US: is follow-up an acceptable alternative to biopsy? Radiology. 244(1):87-93, 2007
                                                                  35. Leung JW et al: The probably benign assessment. Radiol Clin North Am. 45(5):773-89, vi, 2007
                                                                  36. Liberman L et al: Does size matter? Positive predictive value of MRI-detected breast lesions as a function of lesion size. AJR Am J Roentgenol. 186(2):426-30, 2006
                                                                  37. Rosenberg RD et al: Performance benchmarks for screening mammography. Radiology. 241(1):55-66, 2006
                                                                  38. Kerlikowske K et al: Breast cancer yield for screening mammographic examinations with recommendation for short-interval follow-up. Radiology. 234(3):684-92, 2005
                                                                  39. Sickles EA et al: Performance benchmarks for diagnostic mammography. Radiology. 235(3):775-90, 2005
                                                                  40. Graf O et al: Follow-up of palpable circumscribed noncalcified solid breast masses at mammography and US: can biopsy be averted? Radiology. 233(3):850-6, 2004
                                                                  41. Gordon PB et al: Solid breast masses diagnosed as fibroadenoma at fine-needle aspiration biopsy: acceptable rates of growth at long-term follow-up. Radiology. 229(1):233-8, 2003
                                                                  42. Varas X et al: Revisiting the mammographic follow-up of BI-RADS category 3 lesions. AJR Am J Roentgenol. 179(3):691-5, 2002
                                                                  43. Vizcaíno I et al: Short-term follow-up results in 795 nonpalpable probably benign lesions detected at screening mammography. Radiology. 219(2):475-83, 2001
                                                                  44. Leung JW et al: Multiple bilateral masses detected on screening mammography: assessment of need for recall imaging. AJR Am J Roentgenol. 175(1):23-9, 2000
                                                                  45. Sickles EA: Management of probably benign breast lesions. Radiol Clin North Am. 33(6):1123-30, 1995
                                                                  46. Sickles EA: Nonpalpable, circumscribed, noncalcified solid breast masses: likelihood of malignancy based on lesion size and age of patient. Radiology. 192(2):439-42, 1994
                                                                  47. Sickles EA: Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases. Radiology. 179(2):463-8, 1991