Bahl, Manisha

Abstract High-risk breast lesions (HRLs) encompass a heterogeneous group of pathologies that coexist with an adjacent or synchronous malignancy, confer an increased risk of future breast cancer, or warrant surgical consideration because of upgrade potential or local behavior. Despite their clinical importance, management of HRLs remains variable. The American Society of Breast Surgeons (ASBrS) and the Society of Breast Imaging are collaborating to establish unified, evidence-based guidelines for managing these lesions. While these recommendations are currently in development, this review summarizes the existing literature and current guidance, including ASBrS recommendations, to provide context for multidisciplinary management. The article reviews the histopathologic features, imaging appearance, and management strategies for HRLs, including atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), flat epithelial atypia (FEA), papillomas with and without atypia, radial scar/complex sclerosing lesion (RS/CSL), mucocele-like lesion (MLL), desmoid tumor, and pseudoangiomatous stromal hyperplasia (PASH). Recent literature supports nonoperative management for specific radiologic-pathologic concordant lesions, particularly limited ADH, pure FEA, and pure RS, highlighting the important role of multidisciplinary discussion for personalized care. Lesions such as LCIS subtypes, papilloma with atypia, and MLL with atypia continue to warrant excision due to higher reported upgrade rates to malignancy. Beyond short-term management, HRLs such as ADH, ALH, and LCIS serve as biomarkers of long-term breast cancer risk, informing recommendations for surveillance, risk assessment, and chemoprevention counseling. Achieving a consensus among radiology, pathology, and surgical disciplines is essential to ensure oncologic safety while minimizing overtreatment in the era of precision breast care.

Abstract The initial method of detection (MOD) refers to the first imaging examination, physical symptom, or clinical sign that prompts further investigation and ultimately leads to a new breast cancer diagnosis. The MOD is assigned at the patient level and falls into 1 of 3 categories: screening in asymptomatic patients, detection by patients or health care providers, or neither of the above. The MOD should be assigned prospectively by the radiologist when interpreting an examination with a final BI-RADS category of 4 or 5, before image-guided biopsy and breast cancer diagnosis. The MOD is not assigned to examinations classified as BI-RADS category 0, 1, 2, 3, or 6, nor is it assigned in the setting of an active breast cancer diagnosis. This Clinical Practice article addresses frequently asked questions and challenging clinical scenarios compiled by the American College of Radiology’s Screening and Emerging Technology Committee to guide consistent MOD assignment. For example, if a patient presents with a lump but is ultimately found to have a suspicious finding requiring biopsy in the contralateral breast, the MOD should reflect the reason for presentation, the patient-detected symptom (Pat), even if the cancer itself is asymptomatic. By increasing awareness of MOD and standardizing MOD reporting practices, radiologists can contribute to improved data collection. While MOD is not currently tracked in U.S. cancer registries, its systematic collection may offer valuable insights into screening effectiveness, technology performance, and disparities in cancer detection. Standardized MOD reporting has the potential to strengthen early detection efforts and improve outcomes across diverse clinical settings.