Suspicion for Sarcoma: Clinical Presentation, Multi-Modality Imaging Evaluation, and Ultrasound Artificial Intelligence-Based Decision Support

<b>Background/Objective</b>: This study aims to better characterize the clinical presentation, histology, and imaging features of breast sarcomas on mammography, ultrasound, and MRI, in addition to analyzing the effectiveness of AI DS in detecting breast sarcomas. <b>Methods</b>: A retrospective review from 2008-2024 yielded 18 patients with histologically proven breast sarcomas with imaging available for review. Mammography was available for 13 lesions, ultrasound for 19 lesions, and MRI for 9 lesions. Imaging features were classified according to the BI-RADS 5th edition lexicon. Images were reviewed by two radiologists, and consensus was obtained regarding imaging features. AI DS was retrospectively applied to the breast masses identified on ultrasound. Data analysis was performed using descriptive statistics. <b>Results</b>: 17 females and 1 male were included in this study. Mammographic findings varied from solitary masses (3/13 [23.1%]), asymmetries (3/13 [23.1%]), architectural distortion (1/13 [7.7%]), skin thickening (3/13 [23.1%]), focal asymmetry with calcifications (1/13 [7.7%]), or no suspicious findings (2/13 [15.4%]). Sonography often revealed masses with an irregular shape (13/16 [81.2%]), non-circumscribed margins (15/16 [93.7%]), hypoechoic echo pattern (10/16 [62.5%]), and vascular flow (12/16 [75%]). MRI showed heterogeneously enhancing masses (6/9 [66.7%]) or isolated skin enhancement (3/9 [33.3%]). AI DS analyzed 16 masses on ultrasound and identified 15 (93.8%) as suspicious. <b>Conclusions</b>: Breast sarcomas had a variable appearance on breast imaging, ranging from a solitary mass to isolated skin findings. Awareness of how breast sarcomas can present across imaging modalities while using AI DS as an aid may help radiologists in making the correct diagnosis of this rare and aggressive disease.