A multimodality approach to the diagnosis of breast hamartomas with atypical mammographic appearance

Abstract: The ultrasonographic appearance of breast hamartomas (BHs) is described and its diagnostic utility is discussed in this study of 27 women with mammographic findings both typical and atypical of BH. The role of computed tomography (CT) in the diagnosis of BH of atypical mammographic appearance is also analyzed. These 27 cases of BH were detected in women submitted to mammographic screening. Ages ranged from 45 to 65 years (mean age 52.6 years). In all cases physical and ultrasonographic examinations were carried out. CT studies were carried out in seven cases. Core biopsy was performed in 18 cases of lesions with a mammographic appearance atypical of BH. Lesions were palpable in 9 cases and nonpalpable in 18. Mammographic appearance was characteristic in nine cases. In 19 cases a hypoechoic solid mass with hyperechoic lines and/or bands was seen. This ultrasonographic image is suspicious of BH. Finally, both CT and core biopsy findings were of great help in the diagnosis of BH in the cases where mammographic and ultrasonographic studies were inconclusive. We consider that a combination of mammography, ultrasonography, CT, and core biopsy is fundamental for the successful diagnosis of breast hamartomas not seen in typical form in mammograms.     

Mucocele-like lesions of the breast: a benign cause for indeterminate or suspicious mammographic microcalcifications

Most earlier reports of mucocele-like lesions (MLL) of the breast have dealt with symptomatic cases in premenopausal women or lesions found incidentally in breast biopsies performed for other reasons. The diagnosis of this lesion has special challenges in the setting of mammographic screening for breast cancer because the imaging characteristics of MLL may mimic those of ductal carcinoma in situ (DCIS), while mucinous carcinoma enters the differential diagnosis on cytologic grounds. This report focuses on our experience with MLLs detected during screening mammography. Cases with MLL as the final histologic diagnosis in our database during January 1992-June 2000 are included. The results of clinical, imaging, cytologic, core biopsy, and histologic examination of these lesions are recorded. The relevant literature is reviewed. Twenty-six cases were found, with a mean patient age of 57.5 years. Microcalcifications were the dominant radiologic abnormality in 22 cases (84.6%). Imaging was considered suspicious or almost certainly malignant in 17 cases (65.4%). Cytology was classified as atypical or suspicious in 17 cases (70.9%). However, open biopsy showed mostly benign changes, including atypical ductal hyperplasia (ADH) in five cases (19.2%). In one case, ADH merged with a 3-4 mm focus of low-grade DCIS. This, the largest series focusing purely on screen-detected MLL, suggests that the combination of clinical, imaging, and cytologic features of screen-detected MLL are different from those of mucinous carcinoma, symptomatic MLL, or incidental MLL. Correlating the cytomorphology of mucinous lesions of the breast with their mammographic appearance may permit more precise preoperative diagnosis.     

CORE BIOPSY FOR MICROCALCIFICATIONS IN THE BREAST

Background : The conventional method of dealing with clustered mammographic microcalcification in the breast when it is of uncertain aetiology is to undertake either a short-term mammographic review or to surgically excise the abnormal area and submit it for histological examination. Stereotactic wide-bore needle biopsy (core biopsy) of microcalcifications is a suitable alternative to surgical biopsy and experience with this technique forms the basis of the present study. Methods : Percutaneous core biopsy has been used at the Wesley Breast Clinic as a means of assessing clustered calcification in 297 cases from November 1992 to October 1995. The procedure is done under local anaesthesia as an outpatient procedure using a Stereotactic attachment to a standard mammography unit. Results : A diagnosis of frank malignancy was made on core samples in 22 cases (7.4%), and in all of these malignancy was confirmed at open surgical biopsy. In a further six women in whom the core biopsy was reported as ‘suspicious of malignancy’, open surgical biopsy confirmed malignancy in three women, lobular in situ carcinoma was found in two women, and atypical ductal hyperplasia in one woman. In two instances the core sample was reported as showing atypical ductal hyperplasia and in those cases, this was confirmed at open surgical biopsy. In 265 cases (89%) the histology of the core revealed appearances of benign breast tissue. Open surgical biopsy has been undertaken in only six of these cases, but in all instances the histology has confirmed a benign process. In the two remaining cases, the procedure was considered to be technically unsatisfactory, and open surgical biopsy was recommended because of doubt about the appearance of the microcalcification. In both instances, malignancy was demonstrated. Conclusions : Core biopsy of clustered mammographic microcalcification of uncertain aetiology is recommended as a satisfactory and reliable alternative to open surgical biopsy. It is less expensive, can be done quickly, produces few complications, and does not produce subsequent mammographic distortion.     

Changing concepts in establishing the diagnosis of breast masses

Experience with 297 consecutive biopsies of breast masses for 235 benign lesions and 62 carcinomas over a thirty month period has been reviewed. The correct preoperative clinical diagnosis was made in 91 per cent of cases. Of patients with carcinoma, 66 per cent were suspected clinically, and 88 per cent of those clinically suspected were confirmed by needle biopsy alone. The mammographic diagnosis was correct in 89 per cent of cases with 6 per cent false-negatives. The clinical and mammographic diagnosis differed in 27 patients, with the clinical diagnosis being correct in 85 per cent. No patient thought to have cancer on both clinical and mammographic grounds had a benign lesion. These data indicate that the approach to establishing a tissue diagnosis in women with breast masses can be simple and inexpensive. Local anesthesia can almost always be employed, and the diagnosis of breast cancer can usually be confirmed with certainty by needle biopsy alone.     

Advanced breast biopsy instrumentation (ABBI) and management of nonpalpable breast abnormalities: a community hospital experience

A range of diagnostic techniques have been in use for determining the nature of non-palpable mammographic abnormalities over the last decade, these include stereotactic and ultrasound guided cytology, core biopsy and vacuum assisted core biopsy techniques as well as open surgical breast biopsy. Recently, a less invasive alternative has been investigated; the Advanced Breast Biopsy Instrumentation (ABBI) technique (U.S. Surgical Corporation, Norwalk, CT). ABBI employs computer-guided stereotactic localization to target and excise mammographic lesions under local anesthesia, without the need for an operating theatre. We conducted a prospective review of all cases involving the use of the ABBI system during the first 17 months' of its use in a community hospital. One hundred and twenty six patients were referred for an ABBI procedure. One hundred fourteen ABBI procedures were performed on 113 patients (average age, 53 years; range, 33-82). The lesion was removed successfully in 113 of the 114 cases. Of the 114 lesions removed with the ABBI system, 88 were microcalcifications and 26 were masses. Cancer was diagnosed in 21 patients (18%). Of the patients who had carcinoma, 11 (52%) had ductal carcinoma in situ, 9 (43%) had infiltrating ductal carcinoma, and 1 (5%) had infiltrating lobular carcinoma. Postprocedural complications occurred in 7 patients (6%); 4 had small haematomas, 2 had superficial wound infections, and 1 had an abscess. We conclude that the ABBI system, is an excellent alternative (to open biopsy after needle localization or large-core biopsy) for nonpalpable breast abnormalities. It has a relatively low complication rate and should be considered as part of the surgical armamentarium for the diagnosis of indeterminate nonpalpable mammographic lesions.     

Selective nonoperative management of patients referred with abnormal mammograms

Screening mammography provides a means of detecting clinically occult breast carcinoma, but the question of whether all abnormal mammograms require biopsy remains unanswered. We retrospectively reviewed records of 214 women referred over an 8-year period for abnormal mammograms. They were selectively assigned to biopsy or mammographic follow-up based on specific mammographic criteria. Of 114 women initially observed mammographically, 2 were later found by biopsy to have carcinoma. Initial assignment to mammographic observation delayed the recommendation for biopsy 3 and 12 months, respectively, in these patients, but no effect on outcome was documented. Because they have benign lesions by clinical and mammographic criteria, 102 women (53%) have been spared biopsy; they continue to be monitored closely. We believe these data support the use of a selective approach to biopsy based on specific mammographic criteria.     

Breast biopsy with needle localization: influence of age and mammographic feature on the rate of malignancy in 350 nonpalpable breast lesions

The purpose of this study was to determine the influence of mammographic feature and patient age on the rate of malignancy in nonpalpable breast lesions. During a 3-year period, 305 patients underwent biopsy after needle localization of 350 nonpalpable breast lesions. A total of 66 malignant breast tumors were found (biopsy yield rate, 19%): 23 carcinoma in situ, 43 infiltrating cancer. The biopsy yield rate in women younger than 50 years was 8% (12 of 153) and in women 50 years or older 27% (54 of 197; p less than 0.001). The biopsy yield rate varied with the mammographic feature in both groups of patients and was highest for spicular masses (61%), followed by strongly suspicious calcifications (29%). No cancers were found among well-defined masses or asymmetric densities. Other factors that were associated with high biopsy yield rate were personal or family history of breast cancer and diagnostic, rather than screening, mammography. The results suggest that the rate of malignancy in nonpalpable breast lesions is influenced by several factors, including age of patient and mammographic feature of the lesion. By taking all these factors into account, biopsies can possibly be performed more selectively thereby increasing the cost effectiveness of biopsy for occult breast cancer.     

Factors associated with upgrading to malignancy at surgery of atypical ductal hyperplasia diagnosed on core biopsy

Previous studies have shown that 4-54% of breast lesions reported on core biopsies as atypical ductal hyperplasia (ADH) are upgraded on further excision to ductal carcinoma in situ (DCIS) or invasive carcinoma. We evaluated the rate of upgrading ADH to carcinoma at surgery for ADH diagnosed by percutaneous biopsy, and examined characteristics associated with malignancy. We identified 13,488 consecutive biopsies conducted at one center over a nine-year period. A total of 422 biopsies with ADH in 415 patients were included. DCIS or invasive carcinoma was found in 132 cases (31.3% upgrading). Multivariate model revealed that ipsilateral breast symptoms, mammographic lesion other than microcalcifications alone, 14G core needle biopsy, papilloma co-diagnosis, severe ADH and pathologists with lower volume of ADH diagnosis were factors statistically associated with malignancy. However, no subgroups were identified for safe clinical-only follow-up. Surgery is recommended in all cases of ADH diagnosed by percutaneous breast biopsy.     

Diagnostic Performance of MR‐guided Vacuum‐Assisted Breast Biopsy: 8 Years of Experience

Breast magnetic resonance imaging (MRI) has demonstrated increased sensitivity over conventional imaging in identifying and characterizing in situ and invasive, multifocal, and multicentric disease. A histologic diagnosis is required for any enhancing lesion displaying suspicious features, especially in the presence of lower and often variable reported specificity values. Breast MRI findings occult on mammography and ultrasound should undergo an MR‐guided biopsy. We retrospectively evaluate our 8 years’ experience with this procedure. Our study included 259 lesions in 255 consecutive patients referred for MR‐guided breast biopsy. MRI screening of women at a high risk for developing breast cancer accounted for 84 lesions, 54 lesions were detected on MRI staging for multifocal and multicentric disease, and 115 were incidental findings or lesions that presented diagnosis related issues on conventional imaging. Six procedures were cancelled due to lack of visualization. MR‐guided breast biopsy was performed for 100 mass and 153 nonmass enhancements. Pathology results were classified into benign (113 lesions), high risk (47 lesions), and malignant (40 ductal carcinoma in situ, 38 invasive ductal carcinoma, 15 invasive lobular carcinoma). Subsequent surgery for high risk and malignant findings revealed an underestimation rate of 34% (16/47) for high risk lesions and of 7.5% for ductal carcinoma in situ (3/40). The overall positive predictive value (PPV) was calculated at 43.1% (33.3% for high‐risk women, 70.3% for cancer staging, and 37.4% for incidental/undetermined lesions). The PPV was higher for mass (57%) versus nonmass enhancements (34%). MR‐guided breast biopsy proved to be a reliable procedure for the diagnosis and management of occult breast MRI findings, or lesions that preclude biopsy under conventional guidance. The PPV displayed significant variation between patient subgroups, correlating higher values with a higher associated breast cancer prevalence.     

Incidence of invasive versus non-invasive carcinoma in comparing palpable and non-palpable solid breast lesions

A retrospective study was done of all patients with a suspicious mammographic breast lesion surgically biopsied in our institution within the last 5 years. Incidence of invasive versus non-invasive carcinoma and stage at presentation (according to TNM classification system) of palpable and non-palpable lesions were compared. We found a significant difference of non-invasive carcinoma in non-palpable and palpable cancers: 42.2% versus 4.3% (p < 0.001). Patients with a non-palpable invasive carcinoma presenting at stage I (i.e. pT1 with no axillary metastasis) rated significantly higher compared to those with palpable lesions 51.8% versus 9.4% (p < 0.001). The true positive biopsy rate is 30%. As low as 10% has been considered reasonable. We have a total of 56% carcinomas detected on all biopsies: 30% for non-palpable lesions and 66.8% for palpable lesions. A more aggressive approach towards screening and biopsy of breast lesions might increase early detection of carcinoma and so improve survival.     

Carcinoma arising from preexisting pregnancy-like and cystic hypersecretory hyperplasia lesions of the breast: a clinicopathologic study of 9 patients

The intimate histologic relationship of pregnancy-like hyperplasia (PLH) and cystic hypersecretory hyperplasia (CHH) has been previously reported. However, none of these published cases contained coexisting carcinoma. In this study, we describe 9 additional cases of this lesion, all of which also revealed ductal carcinoma in situ (DCIS) as well as invasive carcinoma in 1 case. Hematoxylin and eosin-stained slides were reviewed for all cases. All were women who ranged in age from 35 to 49 years (mean 42.0 years; median 42.5 years). Reasons for surgical biopsy were calcifications in 6, breast mass in 2, and nipple discharge in 1. One patient with a mass also experienced nipple discharge. Three women initially underwent needle core biopsy and 6 had an excisional biopsy. Six women ultimately had mastectomies. Histologically, 5 had CHH merging with coexisting PLH. Atypia was seen in one or both components. All 9 cases contained DCIS. Two cases showed micropapillary DCIS, one of which appeared to arise from atypical PLH, while 4 of the 7 cases containing cystic hypersecretory DCIS appeared to arise from coexisting atypical CHH. Well-differentiated invasive carcinoma was identified in 1 case adjacent to cystic hypersecretory DCIS. Subsequent sentinel lymph node biopsy in this case revealed micrometastatic disease. Clinical follow-up was obtained in 9 patients and ranged from 10 to 69 months. All patients were free of disease at the time of last follow-up. Careful clinical follow-up is recommended for lesions that display atypia in PLH, CHH, or a histologically combined lesion. If these lesions are found on a needle core biopsy specimen, an excisional biopsy is recommended. DCIS, usually micropapillary or cystic hypersecretory types, and rarely invasive carcinoma can arise in this setting. Affected patients are typically younger than those with more common types of breast carcinoma.     

The significance of atypical lobular hyperplasia at percutaneous breast biopsy

Atypical lobular hyperplasia (ALH) is occasionally found in specimens obtained by percutaneous stereotactic vacuum-assisted breast biopsy for microcalcifications. Since malignancy is often found at surgical excision when atypical ductal hyperplasia is found at percutaneous biopsy, we reviewed our pathologic findings from surgery for ALH at percutaneous biopsy. This was a retrospective review of all percutaneous breast biopsy specimens for mammographic microcalcifications obtained from a single institution over a 30-month period. The pathologic findings from percutaneous biopsy were correlated with the radiologic appearance and the pathology from surgical excision. ALH was found in 13 of 766 (1.7%) stereotactic vacuum-assisted core needle biopsies performed for mammographic microcalcifications. Subsequent surgery in six patients revealed ductal carcinoma in situ (DCIS) in two patients and one case of invasive ductal carcinoma. Surgical excision is indicated for areas with ALH discovered by percutaneous biopsy for mammographic microcalcifications.     

Assessment of 142 stellate lesions with imaging features suggestive of radial scar discovered during population-based screening for breast cancer

Because some lesions diagnosed as radial scars (RS) on core biopsy have been found to be malignant on excision, core biopsy has not had an established role in the assessment of RS. In our breast cancer-screening program, we have avoided core biopsy if RS is suspected on imaging. Recently, two reports have expanded the experience with core biopsy of RS, prompting this review of our assessment protocols for lesions suspected as being RS. Between January 1996 and January 2003, stellate lesions with imaging features of RS in which core biopsy was omitted because of a presumptive radiologic diagnosis of RS are included. Demographic, radiologic, and cytologic data were correlated with the histologic findings in the excised specimen. On imaging, 9% (142) of all stellate lesions were suspected to be RS. Only 66.2% (94) were confirmed as RS on histology; 38 cases (28.6%) were carcinomas (36 invasive, 2 in situ) and 7% showed benign fibrocystic changes; 87.1% of the carcinomas required further surgery for positive margins. Axillary staging was also needed for the invasive cancers. Among the histologically proven RS, 28 of 94 (29.8%) showed areas of atypical ductal hyperplasia, lobular neoplasia, ductal carcinoma in situ, or invasive carcinoma. These proliferations were typically focal and unpredictable and were usually completely excised by the initial diagnostic biopsy. Core biopsy would be valuable in the assessment of lesions with imaging features suggestive of RS since 28.6% of such lesions are indeed carcinomas that mimic RS. Identification of these cancers would permit one stage breast and axillary surgery to be planned. The policy of mammographic surveillance for lesions with nonmalignant core biopsies remains controversial because of the paucity of data. Ongoing evaluation is needed as more experience is reported.     

All pure flat atypical atypia lesions of the breast diagnosed using percutaneous vacuum-assisted breast biopsy do not need surgical excision

BackgroundThe purposes of this study were to evaluate the outcome of women with pure flat atypical atypia (FEA) diagnosed at vacuum-assisted breast biopsy (VABB) targeting microcalcifications and to determine whether clinical, radiological and pathologic parameters are able to predict which lesions will be upgraded to malignancy.Materials2414 cases of consecutive VABB for microcalcifications using VA 8-, 10- or 11-Gauge stereotactically guided core biopsy performed between January 2005 and December 2011 from two french breast cancer centers were evaluated. Data of women with VABB-diagnosed pure FEA who underwent either excisional surgery or mammographic follow-up were analyzed. Cases with mass lesions or ipsilateral cancers were excluded. Two pathologists (FA,PM) reviewed the results of procedures performed. Clinical, radiological, as well as histological criteria have been studied in order to determine the correlation between these factors and carcinoma underestimation.Results and conclusionThis study included 70 cases of pure FEA. Twenty women underwent surgical excision and 50 had clinical and mammographic surveillance only. In three women FEA was upgraded to breast cancer on excision. Clinical and mammographic follow-up for a mean of 56 months ± 27 in the group without excision showed two cancers in the same breast (Intermediate grade DCIS, and invasive ductal carcinoma 84 and 48 months respectively after VABB). Three factors were significantly predictive of underestimation or occurence of cancer for pure FEA when the radiologic lesions are calcifications: age≥ 57 years, radiologic size >10 mm and number of FEA foci ≥4.     

A better understanding of the term radial scar

BACKGROUND: Radial scar is a breast lesion with mammographic and histologic features similar to carcinoma. We reviewed the characteristics of patients with radial scars to better understand these lesions and to determine the incidence of associated carcinoma. METHODS: Records for all patients undergoing diagnostic wire localized excisional breast biopsy from January 1993 to September 1999 were reviewed to identify those with histologic or mammographic evidence of radial scar. Clinical records, mammograms, and pathologic slides of these patients were reviewed. RESULTS: We identified 45 cases of radial scar: 10 patients had mammographic and histologic evidence of radial scar (group I), 29 only mammographic evidence (group II), and 6 only histologic evidence (group III). Breast cancer risk was similar in the three patient groups. Carcinoma was identified in 18 patients with mammographic radial scars. CONCLUSION: Mammographically detected radial scars were associated with carcinoma in 18 of 39 (46%) cases. Histologically identified radial scars are not associated with malignancy and should not be confused with mammographically identified lesions.     

Experience with fine-wire localization breast biopsies for nonpalpable breast lesions detected mammographically

There is evidence to suggest that the early diagnosis and treatment of breast cancer may be associated with a better prognosis. Technical advances such as mammography can detect nonpalpable breast lesions and changes associated with early carcinoma. With fine-wire localization under mammographic control, the surgeon can reliably remove nonpalpable lesions while sparing normal breast tissue. The authors describe the technique for fine-wire localization and removal of lesions and report their experience over 3 years with 262 women who underwent 269 biopsies for nonpalpable lesions. Four subgroups were identified: screened women who had no indication for mammography other than age, women who were referred for mammography by community physicians, a group referred to the Cancer Control Agency of British Columbia and a group referred to the agency for localization biopsy after mammography performed outside the Vancouver area had suggested a malignant lesion. The yield of cancers from biopsies was 10%, 38%, 43% and 26% respectively. The yield was significantly (p less than 0.05) lower for the screened group. Age over 60 years, previous breast cancer and mammographic technique were identified as possible predictors of a positive biopsy. The authors have found fine-wire localization biopsy a safe and reliable method of removing nonpalpable breast lesions.     

Biopsy needle technique and the accuracy of diagnosis of atypical ductal hyperplasia for mammographic abnormalities

The evaluation of mammographic abnormalities has become a substantial effort for surgeons and radiologists. The vacuum-assisted core biopsy (VACB) has been touted as a more accurate tool for the evaluation of mammographic lesions. Diagnosis of atypical ductal hyperplasia (ADH) from a percutaneous needle biopsy of the breast is associated with a significant risk of missing a significant breast lesion. We compared 2 methods of sampling with stereotactic-guided breast biopsy, 14-gauge automated gun core biopsy (AGCB) and VACB, on the accuracy of diagnosis of ADH at a single institution. All cases of ADH, without associated malignancy, found via image-guided breast biopsy of nonpalpable lesions between March 1996 and April 2002 were evaluated. VACB biopsy needles were utilized between July 1998 to April 2002 (686 patients) and 14-gauge AGCB from March 1996 to June 1998 (350 patients). The results of these biopsies were reviewed and compared to surgical biopsy and pathological records. ADH alone was found in 53 cases (5.1% of biopsies; mean age 57.9 years). Of these, 39 patients with ADH subsequently underwent wire-localized excisional biopsy. The other 14 patients were observed. VACB biopsy understaged 7 of 29 (24%) patients with ADH (all of which were DCIS), AGCB understaged 4 of 10 cases (40%) with one being invasive. Of the patients in the core biopsy group who were initially followed, 2 developed significant lesions within 3 years of follow-up in the same quadrant of the breast. If these cases are added to the AGCB group, then 50 per cent were understaged and significantly more invasive lesions were understaged than with VACB (17% vs. 0%; P = 0.018). The VACB resulted in less understaging of ADH than AGCB. However, there remains a significant risk of missing DCIS in this setting even with the VACB. Furthermore, the risk of understaging an invasive lesion is significantly lower in this setting with a VACB than an AGCB. Although the risk of understaging ADH is lower with the VACB, we continue to recommend excisional biopsy in a good-risk patient when a diagnosis of ADH is rendered via VACB biopsy.     

Presence of Basement Membrane Material around the Tubules of Tubulolobular Carcinoma

BACKGROUND: Core needle biopsies represent only a small portion of a breast lesion. Rare lesions with overlapping features may be underestimated in such small samples. CASE REPORT: A 67-year-old female underwent core needle biopsy of a 27-mm breast tumour demonstrating infiltrative glands without significant desmoplasia. Periglandular collagen IV immunostaining and the small glands were reminiscent of microglandular adenosis, and despite the infiltrative look of the microglands, the lesion was interpreted as suspicious for malignancy. Finally, the tumour proved to be a tubulolobular carcinoma. CONCLUSIONS: The tubules of tubulolobular carcinoma may show a basement membrane-like staining pattern with collagen IV, and this must be considered in the differential diagnosis of mammary lesions with small glandular architecture.     

Wire-guided biopsies of nonpalpable breast lesions

The purpose of this study was to review the results of mammographic wire-guided biopsies of nonpalpable breast lesions and the features of the lesions in the preoperative examinations. Sixty women, mean age 50.2 years (range 31 to 74), underwent a wire-guided biopsy of the lesion. Twenty-nine patients had preoperative fine needle aspiration of the lesion. The radiographic diagnosis was correct in 33 patients (55%); 25 had breast cancer and 8 patients had a benign lesion. In 9 of the 14 patients with clustered microcalcifications in mammography and in 13 of the 15 patients with a mass noted in mammography, the cytological examination was correct. Nonpalpable mammographic masses with regular borders and normal fine needle aspiration examination do not require biopsy. In malignant mammographic appearances associated with a normal fine needle aspiration examination, biopsy of the lesion should always be done.     

Invasive ductal carcinoma of the breast with large central acellular zones (ring carcinoma): imaging and clinical findings in eight cases

OBJECTIVE: To review the mammographic and ultrasound appearances in patients who have invasive ductal carcinoma with a central acellular zone (ring carcinoma), as this feature has been reported to be associated with a poorer outcome. MATERIALS: Eight patients were identified with ring carcinomas. Two breast radiologists reviewed their mammograms and ultrasound images. Patient records were reviewed to assess outcome. RESULTS: All patients had lesions deep within the breast, adjacent to the chest wall, five lesions were incompletely visualised on mammography. The appearance was of a circumscribed or obscured mass, without microcalcification. Five patients had ultrasound demonstrating a solid well-circumscribed hypoechoic microlobulated lesion. CONCLUSION: In our series of patients who have a ring carcinoma of the breast, mammographic and ultrasound appearances were similar in all cases and lacked the typical features of malignancy.