Background
The Breast Imaging Reporting and Data System (BI-RADS) term "architectural distortion" refers to a distortion in the normal architecture of the breast without a discrete mass. Architectural distortions can be associated with both benign and malignant etiologies and may be a subtle finding across all breast imaging modalities. Appropriate identification and management of architectural distortions in breast imaging is facilitated by an understanding of the possible etiologies, associated clinical history, and expected evolution of benign and malignant pathologies.
Educational Goals / Teaching Points
Architectural distortion can be an early sign of invasive carcinoma and has a high association with malignancy. Benign and malignant causes for architectural distortion of the breast and associated clinical history will be reviewed. The appearance of benign and malignant pathologies associated with architectural distortion will be characterized across multiple modalities with histopathologic correlation and an emphasis on Magnetic Resonance Imaging (MRI). The appropriate management and follow-up of architectural distortions will be discussed.
Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Common benign causes of architectural distortion include fat necrosis, postsurgical scar, fibromatosis, trauma, and sclerosing adenosis. Common malignant and high-risk causes of architectural distortion include radial sclerosing lesion, ductal carcinoma in-situ, invasive lobular carcinoma, and invasive ductal carcinoma. Digital breast tomosynthesis is superior compared to conventional 2-dimensional mammography for demonstrating architectural distortions, and the majority of mammographically detected architectural distortions will demonstrate a sonographic correlate. Studies have demonstrated the diagnostic utility of dynamic contrast-enhanced MRI, particularly with diffusion weighted imaging, in characterizing the etiology of architectural distortion to aid management.
Conclusion
Architectural distortion can be a subtle finding on breast imaging but has a high association with malignancy. Familiarity with the imaging findings, relevant clinical history, and associated differential diagnosis is important for appropriate management of architectural distortions when detected on screening or diagnostic evaluation.
