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326
BREAST IMAGING
Nonmass Findings at Breast US:
Definition, Classifications, and Dif-
ferential Diagnosis
Jihee Choe, MD
Sona A. Chikarmane, MD
Catherine S. Giess, MD
Abbreviations: BI-RADS = Breast Imaging
Reporting and Data System, DCIS = ductal car-
cinoma in situ, IDC = invasive ductal carcinoma,
ILC = invasive lobular carcinoma
RadioGraphics 2020; 40:326–335
https://doi.org/10.1148/rg.2020190125
Content Codes:
From the Department of Radiology, Brigham
and Women’s Hospital and Harvard Medical
School, 75 Francis St, Boston, MA 02115. Pre-
sented as an education exhibit at the 2018 RSNA
Annual Meeting. Received April 20, 2019; revi-
sion requested May 30 and received August 5;
accepted August 9. For this journal-based SA-
CME activity, the authors, editor, and review-
ers have disclosed no relevant relationships.
Address correspondence to J.C. (e-mail:
jchoe@bwh.harvard.edu).
©
RSNA, 2020
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
Recognize the sonographic features of
„
nonmass findings at breast US.
Describe the correlation between US
„
features and MRI features for nonmass
findings.
Identify the benign and malignant
„ Introduction
causes of nonmass findings at US.
See rsna.org/learning-center-rg.
A nonmass finding at US has been described as a discrete identifi-
able area of altered echotexture compared with that of the surround-
ing breast tissue that does not conform to a mass shape. Recognizing
nonmass findings is important because breast cancer can manifest
as such lesions, and US correlate findings for mammographic and
breast MRI abnormalities may manifest as nonmass findings. The
term nonmass finding is not part of the current Breast Imaging
Reporting and Data System US terminology, and no standardized
approach to classify and evaluate nonmass findings at US currently
exists, despite the various classification systems proposed in the lit-
erature. There is also considerable overlap between the sonographic
features of benign and malignant causes of nonmass findings. These
limitations cause diagnostic difficulty in evaluating clinical signifi-
cance and recommending appropriate management. The authors
review the definitions and classification systems of US nonmass find-
ings proposed in the literature and illustrate the sonographic features
of nonmass findings to help radiologists identify them at US. A range
of benign and malignant causes of nonmass findings are reviewed,
and sonographic-histopathologic correlations of nonmass findings
are discussed. Cases of breast MRI and mammographic findings that
may manifest as US nonmass findings are presented. Radiologists
can improve detection and interpretative accuracy, as well as correla-
tion of mammographic and MRI breast lesions, by increasing their
recognition and understanding of nonmass findings at US.
©
RSNA, 2020 • radiographics.rsna.org
A nonmass finding at US is a discrete identifiable area of altered
echotexture compared with that of the surrounding breast tissue that
does not conform to a mass shape. The term nonmass finding is not
included in the current Breast Imaging Reporting and Data System
(BI-RADS) US lexicon (1). The current BI-RADS descriptive lexicon
for the findings depicted at breast US includes masses (ie, space-
occupying lesions depicted in two different projections), calcifications,
and associated features. However, radiologists occasionally encounter
breast lesions that may not meet the exact BI-RADS US criteria. The
reported incidence of nonmass findings at screening whole-breast US
is 1.0%–5.3% (2,3). In addition, US correlates for mammographic
abnormalities, such as developing and focal asymmetries and nonmass
enhancement at MRI, may manifest as nonmass findings (4–7).
Owing to the lack of unified terminology describing these US find-
ings, nonmass findings have been described using a variety of terms
and phrases in the literature, such as a “vague area of altered echotex-
ture,” “nonmass image-forming lesions,” “nonmasslike lesions,” and
“nonmass lesions.” The multiplicity of the names suggests variations
in recognition and interpretation of these lesions among radiologists in
clinical practice. More important, a wide range of benign and malig-
nant pathologic conditions appear as nonmass findings on US images.
RG  •  Volume 40  Number 2 Choe et al  327

TEACHING POINTS Table 1: Definitions of Nonmass Findings in

„ Nonmass findings have been described in the literature with the Literature
various terms with varying descriptors, but all studies define a
Study Definition
nonmass finding as a sonographic finding that does not con-
form to a mass shape (ie, nonconvex borders). Kim et al A hypoechoic area that is different
„ On the basis of the definitions and various classifications de- (2) from surrounding glands
scribed in the literature, we have found it useful to categorize Giess et al Identifiable discrete areas of altered
nonmass findings by echogenicity and distribution. We have (4) echotexture compared with sur-
focused on echogenicity in our classification system for two rounding breast tissue depicted on
reasons: (a) echogenicity is a primary feature in the detection
orthogonal images and not con-
of a nonmass finding at US, and (b) nonmass lesions with a
forming to a mass (convex) shape
large hyperechoic component may be difficult to recognize
as a lesion distinct from heterogeneous background tissue. Park et al A lesion visible in two orthogonal
Associated features include tubular or ductal architecture, pos- (8) planes that cannot be characterized
terior shadowing, architectural distortion, and calcifications. as a distinct mass because of a lack
„ A nonmass finding has been described with benign entities of conspicuous margin or shape
but may also occur in malignant lesions. Nonmass findings Ko et al (9) A lesion showing ductlike hypoecho-
are benign in 46%–90% of cases, with malignancy rates for ic structures with parallel orien-
nonmass findings reported in the literature as ranging from tation, geographic hypoechoic
10% to 54%. changes that differ from surround-
„ The most common breast cancers identified as nonmass find- ing glandular tissue or the same
ings on US images were DCIS or ILC. area in the contralateral breast, or
„ Accurate identification of a US correlate for mammographic architectural distortion without a
abnormalities is an important component of diagnostic evalu- definitive mass
ation. Mammographic lesions that most often appear as non- Wang et al A lesion on a conventional US image
mass findings on US images include calcifications, a focal or (10) that does not meet the strict criteria
developing asymmetry, and architectural distortion. of a mass
Shin et al A lesion with minimal or no mass
(11) effect, a focal heterogeneity distin-
Therefore, accurate identification and interpreta- guished from the adjacent normal
breast parenchyma, or calcifica-
tion of a nonmass finding is essential to improve
tions not associated with a mass;
the sensitivity and specificity of breast US.
can have areas or spots of normal
In this article, we review the definitions and glandular tissue or fat interspersed
various proposed classification systems for non- with these lesions
mass findings described in the literature, illustrate Ko et al (12) A lesion that is difficult to recognize
the US features of breast nonmass findings, dis- as a mass, a lesion with minimal or
cuss sonographic and histopathologic correlations, no mass effect, or a focal hetero-
and present a range of benign and malignant geneity distinct from the adjacent
causes of nonmass findings, with an emphasis on normal breast parenchyma, which
correlative mammographic and MRI findings. may represent dilated ducts
Note.—Numbers in parentheses are references.
Definition and Classification
of Nonmass Findings
Nonmass findings have been described in the
literature with various terms with varying de- Association of Breast and Thyroid Sonology guide-
scriptors, but all studies define a nonmass finding lines. In their study, lesions with ductal hypoechoic
as a sonographic finding that does not conform areas were not included, which differed from the
to a mass shape (ie, nonconvex borders) (Table Japan Association of Breast and Thyroid Sonology
1) (2,4,8–12). There is no widely accepted clas- guidelines, because the authors thought the ductal
sification system for nonmass findings, and the hypoechoic areas overlapped with ductal changes
proposed classification systems in the literature defined in the BI-RADS US lexicon.
are quite varied (Table 2). Uetmatsu (14) classified nonmass findings on
The classification of nonmass findings was the basis of whether the findings were reminiscent
proposed as early as 2004 by the Japan Associa- of the milk duct system or not. Ko et al (12) classi-
tion of Breast and Thyroid Sonology (13). In their fied nonmass findings into four types: (a) a ductal
guidelines, a nonmass finding was classified on the hypoechoic area, (b) a nonductal hypoechoic area,
basis of the pattern of distribution and the pres- (c) a vague area of altered echotexture with associ-
ence of associated calcifications (13). The clas- ated architectural distortion, and (d) an indistinct
sification system for nonmass findings in a 2014 hypoechoic area with associated posterior acoustic
study by Kim et al (2) was adapted from the Japan shadowing. Wang et al (10) classified nonmass
328  March-April 2020 radiographics.rsna.org

Table 2: Classification of Nonmass Findings, Patterns, and Distributions in the Literature

Study Classifications
Kim et al (2) Nonmass finding patterns:
Mottled: a number of small hypoechoic islands of tissue
Geographic: confluent hypoechoic areas without a cobblestone appearance that resemble
geographic maps
Indistinct: relatively uniform hypoechoic areas without clearly defined margins
Nonmass distributions:
Focal distribution: involving less than one quadrant of the breast
Regional distribution: involving more than one quadrant of the breast
Giess et al (4) Nonmass finding echotexture was categorized as predominantly (>50%) hypoechoic, pre-
dominantly hyperechoic, mixed hyperechoic and hypoechoic, or predominantly anechoic
Associated findings: echogenic halo, shadowing, calcifications, architectural distortion, or
ductal or tubular architecture
Park et al (8) Distribution of nonmass findings:
Focal: small confined area
Linear-segmental: longitudinal or triangular area arrayed in a line or along the branches
involving one or more ducts
Regional: large geographic area of tissue that does not conform to a ductal or segmental
distribution
Associated features: calcifications, architectural distortion, and abnormal ductal changes
Wang et al (10) Nonmass findings were classified as:
Hypoechoic area (an area with low-level echoes)
Hypoechoic area with sporadic or scattered microcalcifications
Architectural distortion (an area with disordered organization structure compared to that
of normal tissue)
Solid echogenicity within a duct (solid lesion within a duct)
Ko et al (12) Nonmass findings were classified into four types:
Type 1: ductal hypoechoic area with ductal structures and parallel orientation, with and
without calcifications
Type 2: nonductal hypoechoic area visible as a confined asymmetry with an indistinct
shape on two different projections, with and without calcifications
Type 3: vague area of altered echotexture with associated architectural distortion
Type 4: indistinct hypoechoic area with associated posterior acoustic shadowing
Japan Association Nonmass findings were classified as:
of Breast and Ductal dilatation
Thyroid Sonol- Multivesicular pattern
ogy (13) Low-echo area in the mammary gland (spotted or mottled low-echo areas, geographic low-
echo areas, or low-echo areas with indistinct margins)
Architectural distortion
Uematsu (14) Nonmass findings were classified as:
Ductal hypoechoic area: ductlike structure with parallel orientation
Single ductal hypoechoic area
Multiple ductal hypoechoic areas
Nonductal hypoechoic area: an area with an indistinct shape at different projections but
   lacking convex outer borders and conspicuity
Focal nonductal hypoechoic area: a nonoriented hypoechoic area occupying a volume
of less than one quadrant of the breast
Segmental nonductal hypoechoic area: a triangular or cone-shaped hypoechoic area
with the apex pointing to the nipple
Associated findings: calcifications and architectural distortion
Multiple, bilateral, and diffuse hypoechoic areas are considered normal variations or changes
caused by hormonal influences unless there is a corresponding palpable abnormality
Note.—Numbers in parentheses are references.

findings into four categories on the basis of distri- The distribution of nonmass findings was
bution patterns, and simple ductal dilatation was classified as focal, linear, or regional in a study
not considered a nonmass finding. by Park et al (8), and the associated features
RG  •  Volume 40  Number 2 Choe et al  329

Figure 1.  Internal echotexture of nonmass findings at US. (a) Hypoechoic nonmass finding in a 41-year-old woman with archi-
tectural distortion in the right breast at mammography (not shown). US image shows a corresponding predominantly hypoechoic
nonmass finding (arrows), which was subsequently biopsied under US guidance. The results of a pathologic examination con-
firmed a complex sclerosing lesion, cysts, and columnar cell change. The results of a surgical excision confirmed ductal carcinoma in
situ (DCIS). (b) Mixed echogenic nonmass finding in a 61-year-old woman with a focal asymmetry in the right breast at mammog-
raphy (not shown). US image shows a corresponding nonmass finding (arrows) with mixed echogenicity, which was biopsied under
US guidance. The results of a pathologic examination revealed epithelial hyperplasia, columnar cell changes, and pseudoangiomatous
stromal hyperplasia (PASH). (c) Hyperechoic nonmass finding in a 40-year-old woman who presented with a palpable concern in the
right breast and a negative diagnostic mammogram. Diagnostic US image shows a predominantly hyperechoic nonmass finding (ar-
rows) that was biopsied under US guidance. The results of a pathologic examination confirmed fibroadenomatous changes and PASH.

Figure 2.  Suggested distribution of nonmass findings. (a) Nonmass finding with focal distribution in a 57-year-old woman with archi-
tectural distortion in the left breast at mammography (not shown). US image shows a corresponding focal hypoechoic nonmass finding
(arrows), which was biopsied under US guidance. The results of a pathologic examination confirmed a radial sclerosing lesion, usual
hyperplasia, and apocrine metaplasia. (b) Nonmass finding with linear-segmental distribution in a 67-year-old woman who presented
with left breast bloody nipple discharge and a palpable mass, with focal asymmetry and architectural distortion depicted at mammogra-
phy (not shown). US image shows a corresponding hypoechoic nonmass finding (arrows) with ductal architecture in a linear-segmental
distribution. The results of a US-guided core biopsy of the nonmass finding confirmed a focus of dense stromal fibrosis, which was
considered discordant. The results of a surgical excision confirmed invasive ductal carcinoma (IDC) with DCIS. (c) Nonmass finding with
regional distribution in a 40-year-woman who presented with a palpable concern in the right breast, with a developing asymmetry de-
picted at mammography (not shown). US image shows a corresponding nonmass finding (arrows) with regional distribution. The results
of a US-guided core biopsy confirmed fibrous breast tissue. The patient underwent surgical excision given that the finding was palpable
and there was developing asymmetry at mammography. The results of the pathologic examination confirmed lobular carcinoma in situ.

considered included calcifications, architectural architecture, posterior shadowing, architectural

distortion, and abnormal ductal changes. Giess
et al (4) classified nonmass findings on the basis
of echotexture and associated findings, includ-
ing echogenic halo, shadowing, calcifications,
architectural distortion, and ductal or tubular
architecture.
US Features of Nonmass Findings
On the basis of the definitions and various clas-
sifications described in the literature, we have
found it useful to categorize nonmass findings by
echogenicity and distribution. We have focused
on echogenicity in our classification system for
two reasons: (a) echogenicity is a primary feature
in the detection of a nonmass finding at US, and
(b) nonmass lesions with a large hyperechoic
component may be difficult to recognize as a le-
sion distinct from heterogeneous background tis-
sue. Associated features include tubular or ductal
distortion, and calcifications.
Based on visual analysis, the echogenicity of
nonmass findings can be predominantly (>50%)
hypoechoic, predominantly hyperechoic, mixed
hyperechoic and hypoechoic, or predominantly
anechoic (Fig 1). The distribution of nonmass
findings can be classified as focal, linear-seg-
mental, or regional (Fig 2). The distribution of
a focal area can be described as a small con-
fined area. Linear-segmental distribution is a
longitudinal or triangular area arrayed in a line
along a ductal distribution. The distribution of a
nonmass finding in a large geographic area not
conforming to a ductal or segmental distribu-
tion is described as regional. Associated features
add further description to nonmass findings
and include tubular and/or ductal architecture,
posterior shadowing, architectural distortion,
and calcifications.
330  March-April 2020 radiographics.rsna.org
Correlations with Histopathologic
Findings and Benign and Malignant
Histologic Findings
The US feature of a nonmass finding consis-
tently associated with malignancy is the pres-
ence of associated calcifications (Fig 3). Calci-
fications may be visualized as echogenic foci at
US and when detected should be regarded as
suspicious for malignancy. Calcifications de-
picted on US images have been reported to be
more than three times more likely to be malig-
nant than those that were not depicted, possibly
because calcifications associated with benign
tissue may be obscured by echogenic breast
parenchyma (7,15,16).
Kim et al (2) found calcifications in 40% of
malignant nonmass findings, whereas none of
the benign nonmass findings had calcifications at
US (2). Park et al (8) also reported that calcifica-
tions were more frequently depicted in malignant
(27%) compared with benign (10%) nonmass
findings (8). Finally, Choi et al (17) demon-
strated that calcifications were present in 51% of
malignant nonmass findings compared with 2%
of benign nonmass findings. Associated calcifica-
tions may be visualized in cases of IDC, DCIS,
atypical ductal hyperplasia, lobular carcinoma
in situ, fibroadenoma, radial scar, and tubular
adenoma (16,18). The histologic entities that can
be visualized with various associated features of
nonmass findings are listed in Table 3.
While there are benign causes of nonmass find-
ings with associated tubular or ductal architecture,
ductal changes may represent the ductal spread of
cancer cells and can be visualized in DCIS (Fig
4) (7,15,19,20). The enlargement of the ducts in
DCIS has been ascribed to tumor cells or necrosis
within the duct lumen, periductal lymphocytic
reaction, or periductal desmoplasia (7).
Posterior acoustic shadowing may indicate
pathologic changes inciting desmoplastic reac-
tion that can attenuate the ultrasound beam and
are described in both benign and malignant con-
ditions (Fig 5). It may be visualized in cases of
invasive carcinoma, postoperative scar, complex
sclerosing lesion, and fibrous or dense breast
tissue (21,22).
Architectural distortion can be attributed to
pathologic changes distorting ducts within the
adjacent fibroglandular tissue or straightening
nearby Cooper ligaments (Fig 6) (11). Both
benign and malignant lesions can cause archi-
tectural distortion. Benign conditions such as
fibrosis, sclerosing adenosis, and fat necrosis can
disrupt the normal breast parenchymal architec-
ture. Architectural distortion is also depicted in
cases of malignancy and can be due to retrac-
tion of the tissue around the tumor or the tumor
Figure 3.  Calcifications associated with nonmass findings
at US in an 86-year-old woman. US image shows a nonmass
finding (white arrows) with mixed echogenicity with associated
calcifications (black arrows) at the area of mammographic fine
pleomorphic and linear-branching calcifications (not shown).
The results of a US-guided core biopsy confirmed atypical apo-
crine proliferation with necrosis, which was considered a discor-
dant finding. Surgical excision was recommended. The results of
surgical pathologic examination confirmed DCIS.
Table 3: Histopathologic Entities of Associ-
ated Features of Nonmass Findings
Associated
Feature Histopathologic Entities
Calcifications IDC, DCIS, atypical ductal hyper-
plasia, lobular carcinoma in situ,
fibroadenoma, radial scar, and
tubular adenoma
Ductal or IDC, DCIS, intraductal papilloma,
tubular ar- atypical ductal hyperplasia, atypi-
chitecture cal lobular hyperplasia, fibrocys-
tic changes, and ductal ectasia
Posterior Invasive carcinoma, postoperative
acoustic scar, complex sclerosing lesion,
shadowing and fibrous or dense breast tissue
Architectural Invasive carcinoma, DCIS, fibrosis,
distortion sclerosing adenosis, fat necrosis,
and radial scar and/or complex
sclerosing lesion
itself, tumor extension into the Cooper ligament,
or fibrosis caused by shrinkage of breast paren-
chyma following chemotherapy (23).
Architectural distortion is a more frequent as-
sociated feature of nonmass findings in malignant
lesions than in benign lesions (8). Little is known
about the prognostic value of other associated
features of nonmass findings, including poste-
rior acoustic shadowing and tubular or ductal
architecture.
The malignancy rate by echotexture of non-
mass findings is not known. According to the
BI-RADS atlas, the echotexture of masses is not
predictive of a histopathologic finding (1). Giess
et al (4) demonstrated that out of a total of four
cases of malignant nonmass findings, three cases
had mixed echotexture (75%) and one case was
hypoechoic (25%) (4). However, no studies have
RG  •  Volume 40  Number 2 Choe et al  331

Figure 4.  Tubular or ductal archi-

tecture associated with nonmass
findings. (a) Benign condition de-
picted as a nonmass finding with
associated tubular or ductal archi-
tecture in a 25-year-old woman
who presented with a palpable
concern in the left breast. Diag-
nostic US image shows a nonmass
finding (arrows) with tubular-ductal
architecture. The results of a US-
guided core biopsy confirmed a complex sclerosing and papillary lesion with intraductal hyperplasia and apocrine metaplasia. (b) Ma-
lignant condition depicted as a nonmass finding with associated tubular-ductal architecture in a 72-year-old woman. US image shows a
focal nonmass finding (arrows) with tubular-architectural distortion. The results of a US-guided core biopsy confirmed DCIS.

Figure 5.  Posterior acoustic shad-

owing associated with a nonmass
finding at US. (a) Benign condi-
tion depicted as a nonmass finding
with posterior acoustic shadowing
in a 57-year-old woman. US image
shows a hypoechoic nonmass find-
ing with posterior acoustic shad-
owing (arrows), corresponding to
mammographic architectural dis-
tortion (not shown). The results of
a US-guided core biopsy and sur-
gical excisional biopsy confirmed
dense fibrous tissue. (b) Nonmass
finding with posterior acoustic
shadowing in a malignant condition in a 74-year-old woman. US image shows a focal nonmass finding with mixed echogenicity (white
arrows) with associated posterior acoustic shadowing (black arrows), corresponding to a palpable concern and mammographic focal
asymmetry (not shown). The results of a US-guided core biopsy confirmed invasive lobular carcinoma (ILC).

17% in benign nonmass findings. Kim et al (2)

Figure 6.  Architectural distortion associated
with a nonmass finding at US in a 40-year-old
woman. US image shows a hypoechoic nonmass
finding with radiating lines (arrows), suggest-
ing architectural distortion at the site of mam-
mographic architectural distortion (not shown).
The results of a US-guided core biopsy confirmed
benign breast parenchyma with dense fibrous
stroma, focal lymphocytic mastitis, and histio-
cytic reaction.
been performed to establish the prognostic value
of echotexture of nonmass findings in distinguish-
ing between benign and malignant lesions.
Park et al (8) reported that linear-segmental
distribution was more commonly depicted in ma-
lignant nonmass findings than in benign lesions.
In their study, 45% of malignant nonmass findings
had linear-segmental distribution, compared with
classified the distribution of nonmass findings into
only two categories, focal and regional distribu-
tion, and reported that benign nonmass findings
predominantly showed focal distribution, whereas
malignant nonmass findings more frequently
showed regional distribution.
A nonmass finding has been described with
benign entities but may also occur in malignant
lesions. Nonmass findings are benign in 46%–
90% of cases, with malignancy rates for nonmass
findings reported in the literature as ranging from
10% to 54% (2,3,9–12).
Benign lesions that may manifest as nonmass
findings are broad (Fig 7). Kim et al (2) reported
that the most common benign histopathologic
finding (75%) in a nonmass finding was fibro-
cystic change. Nonmass findings can manifest in
both invasive and noninvasive breast cancer, as
well as in nonprimary breast malignancies (Fig
8). The various reported benign and malignant
entities of US nonmass findings are listed in
Table 4 (8,10,11,17).
The most common breast cancers identified as
nonmass findings on US images were DCIS (Fig
9) or ILC (7,11). It has been reported that 11%–
19% of DCIS cases manifest as nonmass find-
ings (12,24). ILC is another type of malignancy
332  March-April 2020 radiographics.rsna.org

Figure 7.  Benign entity that presented as a nonmass finding at US in a 58-year-old woman. (a, b) Lateral (a) and
craniocaudal spot compression (b) mammograms (obtained with digital breast tomosynthesis) of the right breast
show architectural distortion at the 6-o’clock position. (c, d) Orthogonal targeted US images show a corresponding
hypoechoic linear nonmass finding (arrows). The results of a US-guided core biopsy and surgical excision confirmed
atypical ductal hyperplasia.

Figure 8.  Malignant entity that

manifested as a nonmass finding
at US in a 50-year-old woman.
Orthogonal US images of the right
breast show a focal hypoechoic
nonmass finding (arrows) at the
site of mammographic architec-
tural distortion (not shown). The
results of a US-guided core biopsy
confirmed IDC.

that tends to be depicted as a nonmass finding
on US images, likely owing to its characteristic
noncohesive and infiltrative growth pattern.
Selinko et al (25) reported nonmass findings in
13% of ILC cases.
Correlation between Breast US
and Mammographic Findings
Accurate identification of a US correlate for
mammographic abnormalities is an important
component of diagnostic evaluation. Mam-
mographic lesions that most often appear as
nonmass findings on US images include calci-
fications, a focal or developing asymmetry, and
architectural distortion (9,12) (Figs 10, 11).
Shetty and Watson (6) evaluated US features
of mammographically detected focal asym-
metries. In this study population, 35% of focal
asymmetry cases that had a US correlate de-
picted nonmass findings on US images, which
are described as echogenic tissue in their study
(6). Other investigators found that US correlates
for 10%–54% of mammographically detected
developing asymmetry cases had nonmass find-
ings (4,5). Giess et al (4) studied US features of
developing asymmetries and found that 42 of 78
US correlates (53%) had nonmass findings.
Park et al (8) reported that malignant nonmass
findings at US are more often associated with
mammographic abnormalities than are benign
nonmass findings, as 84% of malignant nonmass
findings had corresponding mammographic
abnormalities, compared with 40% in benign non-
mass findings in their study.
RG  •  Volume 40  Number 2 Choe et al  333

Table 4: Reported Benign and Malignant En-

tities of Nonmass Findings
Benign entities
Abscess
Apocrine metaplasia
Atypical ductal hyperplasia
Chronic granulomatous inflammation
Diabetic mastopathy
Duct ectasia
Fat necrosis
Fibroadenoma
Fibrocystic changes
Fibrosis
Lobular carcinoma in situ
Normal breast tissue
Papillomatosis
Plasma cell mastitis
Radial scar
Sclerosing adenosis
Malignant entities
Acute lymphatic leukemia
DCIS
IDC
ILC
Invasive mixed (ductal and lobular) carcinoma Figure 9.  DCIS manifesting as a nonmass finding at
Invasive papillary carcinoma US. Two orthogonal US images of right breast in a 74-
Metaplastic carcinoma year old woman show a focal nonmass finding with
Metastasis mixed echogenicity at the site of a mammographic de-
Mucinous carcinoma veloping asymmetry (not shown). The results of a US-
guided core biopsy confirmed DCIS.

Figure 10.  Nonmass finding as a US correlate of mammographic architectural distortion in a 69-year-old woman.
(a, b) Mediolateral oblique (a) and craniocaudal (b) mammograms with tomosynthesis of the left breast show
architectural distortion (circle). (c, d) Orthogonal targeted US images show a corresponding focal hypoechoic
nonmass finding (arrows). The results of an excisional biopsy confirmed invasive carcinoma with ductal and lobu-
lar features and DCIS.
334  March-April 2020 radiographics.rsna.org

Figure 11.  Nonmass finding as a US correlate of mammographic focal asymmetry in a 67-year-old woman with a history of lupus.
(a, b) Mediolateral oblique (a) and craniocaudal (b) screening mammograms show a focal asymmetry (arrow) in the upper inner
left breast. (c, d) Orthogonal targeted US images shows a focal predominantly hyperechoic nonmass finding (arrows) at the site
of mammographic focal asymmetry. The results of a US-guided core biopsy confirmed atypical lymphoid infiltrate, compatible
with lupus mastitis.

Figure 12.  Nonmass finding as a

US correlate of MRI nonmass en-
hancement in a 69-year-old woman
with a history of BRCA2 mutation.
(a, b) Axial subtraction (a) and
sagittal contrast-enhanced (b) MR
images show a focal nonmass en-
hancement (arrow) in the left breast.
(c, d) Orthogonal focused US im-
ages show a corresponding focal
nonmass finding (arrows) with
mixed echogenicity. The results of
an MRI-guided core biopsy con-
firmed ILC.

US-guided biopsy is generally preferred Correlation between Breast US

because it is less expensive and better tolerated
by patients. Given the subtle nature of nonmass
findings, performing stereotactic core biopsy
may be preferable when there is sonographic
uncertainty.
and MRI Findings
A nonmass finding may be a sonographic cor-
relate for an MRI abnormality (Fig 12). Wang
et al (7) reported that US correlates for DCIS,
which appear as nonmass enhancement at MRI,
RG  •  Volume 40  Number 2 Choe et al  335
included “vague areas of decreased echogenicity
or altered echotexture,” or nonmass findings.
Similarly, nonmass findings at US tend to appear
as nonmass enhancement at MRI as well. Sotome
et al (26) found that 40% of nonmass findings
at US have corresponding enhancing lesions at
MRI, and of these findings, 97% were nonmass
enhancement at MRI. In the same study, 95% of
malignant nonmass findings at US showed non-
mass enhancement at MRI (26).
Conclusion
Radiologists may encounter nonmass findings at
screening and diagnostic US. Nonmass findings
are significant because they may indicate malig-
nancy, especially if associated with calcifications
depicted on US images, and may be imaging
correlates for mammographic and MRI findings.
The appearance of nonmass findings on US im-
ages can be subtle. However, suspicion should be
raised, especially if nonmass findings are detected
on US images in the expected location of a
suspicious mammographic or MRI finding. The
current published literature of nonmass enhance-
ment provides varied definitions and classifica-
tion systems. In this review, we suggest evaluating
nonmass findings on US images by assessing
internal echotexture, distribution, and associated
findings. Further studies are needed to validate
these categories with histopathologic correlation.
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