Multimodality imaging findings of hematological malignancies involving the breast: a retrospective analysis based on the updated BI-RADS v2025 Manual

BACKGROUND: Hematological malignancies involving the breast are rare and can mimic primary breast carcinomas. The recent release of the ACR BI-RADS v2025 Manual introduces updated descriptors that may enhance the characterization of breast lesions. AIMS: This study aims to characterize the multimodality imaging features of histopathologically proven breast involvement in lymphoma, leukemia, and plasmacytoma, specifically utilizing the BI-RADS v2025 Manual. METHODS: We retrospectively analyzed the clinical and radiological data of 25 patients with primary or secondary hematological breast involvement. Imaging findings from mammography (MG), ultrasound (US), elastography, and magnetic resonance imaging (MRI) were evaluated. RESULTS: The cohort (mean age: 50.4 ± 17.6 years) showed a high prevalence of secondary involvement (96%), multifocal (64%), and bilateral (36%) disease. On MG, an equal-to-high-density mass with a lobulated shape and obscured margins, without associated microcalcifications, was the predominant finding. US most frequently demonstrated a lobulated mass with indistinct margin, heterogeneous echotexture, and parallel orientation, often accompanied by an echogenic rind and posterior acoustic enhancement. On elastography, approximately 60% of lesions exhibited intermediate stiffness. MRI typically revealed T2-hyperintense mass with heterogeneous contrast enhancement and marked diffusion restriction (low ADC values). Axillary lymphadenopathy was present in 52% of the cases. CONCLUSION: Hematologic malignancies typically present as lobulated shape, non-calcified masses with obscured or indistinct margins, intermediate elasticity, and marked diffusion restriction. Awareness of these patterns within the BI-RADS v2025 framework is essential for achieving a precise diagnosis and will prevent unnecessary surgical interventions.