Breast lumps diagnostic study of choice
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shadan Mehraban, M.D.[2]
Overview
Mammography is the gold standard test for the diagnosis of breast lumps in women aged >40 years old. Ultrasound is the gold standard test for the diagnosis of breast lumps in women aged <40 years old. Management and medical therapy of breast lumps depends on women's age (age> 40 or age <40) and mammography results in women aged > 40 years. In women aged > 40 years; no further evaluation is needed in case of clearly benign mass in mammography; however, ultrasound imaging is required for the rest of the findings mammography. Approach to breast lumps in women >40 years is depended on breast imaging reporting and data systems (BI-RADS) stages. Medical therapy of breast lumps in women< 40 years is depended on ultrasound results and BI-RADS categories.
Diagnostic Study of Choice
Gold Standard
Mammography
Mammography is the gold standard test for the diagnosis of breast lumps in women aged >40 years old.[1]
- If the patient had positive history of bilateral mammography within past 6 months, only ipsilateral mammography is needed.
Ultrasound
Ultrasound is the gold standard test for the diagnosis of breast lumps in women aged <40 years old.[1]
The comparison of various diagnostic studies for breast lumps:[2]
| Sensitivity | Specificity | |
|---|---|---|
| Ultrasound | 82% | 84% |
| Mammography | 49% | 89% |
Breast ultrasound has higher sensitivity and mammography has higher specificity. The accuracy of ultrasound reported as 84% and accuracy of mammography reported as 81% .[2]
Diagnostic Approach to Breast Lump
Diagnostic approach for breast lump:
- Women aged >40 years with palpable mass:[3]
- Diagnostic mammography is considered as the first step.
- If the last screening test is related to more than previous 6 months, both breast mammography is required to rule out occult malignancy.
- No further evaluation is needed in case of clearly benign mass in mammography.
- Ultrasound imaging is required for the rest of cases appeared in mammography.
- Stereotactic biopsy is recommended in negative ultrasound findings addition to suspicious mammographic results.
- Women aged< 40 years with palpable mass:[1][4]
- Ultrasound or mammography is suggested for initial management of women aged between 30 to 39 years.
- Ultrasound is the first step for women < 30 years presenting with palpable mass.
Approach to breast lumps in women aged > 40 years based on mammographic results:[3]
- If mammographic results become negative, the next step is targeted ultrasound.
- Negative ultrasound results considered as breast imaging reporting and data system (BI-RADS) 1, then clinical follow-up is needed.
- Benign ultrasound results considered as BI-RADS 2, then clinical follow-up is needed.
- Probably benign results considered as BI-RADS 3, then ultrasound short interval follow-up is needed.
- Suspicious ultrasound results considered as BI-RADS 4 or 5, then core-needle biopsy is needed.
- If mammographic results show only fatty tissue:
- Considered as BI-RADS 1, then clinical follow-up is needed.
- If mammographic results show benign mass:
- Considered as BI-RADS 2, then clinical follow-up
- If mammographic results are in favor of probably benign lumps, the next step is targeted ultrasound.
- Negative ultrasound results considered as BI-RADS 3, then mammographic short interval follow-up is required.
- Benign ultrasound results considered as BI-RADS 2, then clinical follow-up is required.
- Probably benign ultrasound results considered as BI-RADS 3, then ultrasound short interval follow-up.
- Suspicious ultrasound results is considered as BI-RADS 4 or 5, then core needle biopsy is required.
- If mammographic result is in favor of suspicious lesion, the next step is ultrasound to determine biopsy plan.
- Considered as BI-RADS 4 or 5, then core needle biopsy is required.
Approach to breast lumps in women aged <40 years based on targeted ultrasound findings:[3]
- If ultrasound results become negative, there are two approaches:
- Considered as BI-RADS 1, then clinical follow-up is required ( if no palpable dominant suspicious mass found at clinical examination)
- Perform diagnostic mammography:
- Negative results are in favor of BI-RADS 1, then clinical follow-up is required.
- Benign results are considered as BI-RADS 2, then clinical follow-up is required.
- Probably benign results considered as BI-RADS 3, Mammographic short interval follow-up is required.
- Suspicious results considered as BI-RADS 4 or 5, then core needle biopsy is required.
- If ultrasound results show benign findings:
- Considered as BI-RADS 2, then clinical follow-up is required.
- If ultrasound results show probably benign findings:
- Considered as BI-RADS 3, then short interval follow-up is required.
- If ultrasound results become suspicious:
- Considered as BI-RADS 4 or 5, then core needle biopsy is required.
For more information on breast imaging reporting and data system (BI-RADS) system, click here.
| Women age > 40 years | |||||||||||||||||||||||||||||||||||||||||||
| Mammographic findings | |||||||||||||||||||||||||||||||||||||||||||
| Negative | Fatty tissue | Benign | Probably benign | Suspicious | |||||||||||||||||||||||||||||||||||||||
| Ultrasound | BI-RADS 1, then clinical follow-up | BI-RADS 2, then clinical follow-up | Ultrasound | Ultrasound for biopsy plan determination | |||||||||||||||||||||||||||||||||||||||
| BI-RADS 4 or 5, then core needle biopsy | |||||||||||||||||||||||||||||||||||||||||||
| Negative | Benign | Probably benign | Suspicious | ||||||||||||||||||||||||||||||||||||||||
| BI-RADS 3, then mammographic short interval follow-up | BI-RADS 2, then clinical follow-up | BI-RADS 3, then ultrasound short interval follow-up | BI-RADS 4 or 5, then core needle biopsy | ||||||||||||||||||||||||||||||||||||||||
| Negative results | Benign | Probably benign | Suspicious | ||||||||||||||||||||||||||||||||||||||||
| BI-RADS 1, then clinical follow-up | BI-RADS 2, then clinical follow-up | BI-RADS 3, then ultrasound short interval follow-up | BI-RADS 4 or 5, then core needle biopsy | ||||||||||||||||||||||||||||||||||||||||
| Women age < 40 years | |||||||||||||||||||||||||||||||||||||||||||||
| Targeted ultrasound | |||||||||||||||||||||||||||||||||||||||||||||
| Negative | Benign | Probably benign | Suspicious | ||||||||||||||||||||||||||||||||||||||||||
| BI-RADS 2, then clinical follow-up | BI-RADS 3, then short interval follow-up | BI-RADS 4 or 5, then core needle biopsy | |||||||||||||||||||||||||||||||||||||||||||
| BI-RADS 1, then clinical follow-up | Perform diagnostic mammography | ||||||||||||||||||||||||||||||||||||||||||||
| Negative | Benign | Probably benign | Suspicious | ||||||||||||||||||||||||||||||||||||||||||
| BI-RADS 1, then clinical follow-up | BI-RADS 2, then clinical follow-up | BI-RADS 3, Mammographic short interval follow-up | BI-RADS 4 or 5, then core needle biopsy | ||||||||||||||||||||||||||||||||||||||||||
References
- ↑ 1.0 1.1 1.2 Lehman CD, Lee AY, Lee CI (2014). "Imaging management of palpable breast abnormalities". AJR Am J Roentgenol. 203 (5): 1142–53. doi:10.2214/AJR.14.12725. PMID 25341156.
- ↑ 2.0 2.1 Tan KP, Mohamad Azlan Z, Rumaisa MP, Siti Aisyah Murni MR, Radhika S, Nurismah MI; et al. (2014). "The comparative accuracy of ultrasound and mammography in the detection of breast cancer". Med J Malaysia. 69 (2): 79–85. PMID 25241817.
- ↑ 3.0 3.1 3.2 Harvey JA, Mahoney MC, Newell MS, Bailey L, Barke LD, D'Orsi C; et al. (2016). "ACR Appropriateness Criteria Palpable Breast Masses". J Am Coll Radiol. 13 (11S): e31–e42. doi:10.1016/j.jacr.2016.09.022. PMID 27814822.
- ↑ Loving VA, DeMartini WB, Eby PR, Gutierrez RL, Peacock S, Lehman CD (2010). "Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications". AJR Am J Roentgenol. 195 (6): 1472–7. doi:10.2214/AJR.10.4396. PMID 21098212.