This guideline is concerned with imaging of female patients in the adult age group >18 years presenting with palpable breast mass. The recommendations according to the age group are as follows:

ADULT FEMALE, 40 YEARS OF AGE OR OLDER, PALPABLE BREAST MASS:

Variant 1: Initial imaging.

1. Mammography diagnostic:

In women 40 years of age or older with palpable breast mass, mammography is the initial diagnostic imaging modality of choice. Both breasts should be imaged in two views; craniocaudal and mediolateral oblique views enabling the entire breast to be completely screened for any additional lesions. The exam should be done under the supervision of a radiologist and a small radiopaque marker can be placed at the site of the palpable abnormality to assess in localizing the lesion.

Strong recommendation

2. Digital breast tomosynthesis diagnostic:

Diagnostic digital breast tomosynthesis (DBT) is recommended as an initial diagnostic tool. A radio-opaque marker can be applied to the skin to indicate its location.

Strong recommendation

3. Ultrasound breast:

Ultrasound of the breast is used following DBT or DM in this age group particularly if the patient has had a negative DM or DBT in the previous six months.

Strong recommendation

Variant 2: Mammography findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study.

1. Ultrasound breast:

Breast ultrasound is the next imaging modality of choice to characterize suspicious findings detected by DM or DBT. The ultrasound should be performed using a high-resolution linear transducer with a minimum frequency of 12 MHz and an adjustable focal zone.  Examination of the remainder of the breast and the contralateral breast is recommended to search for any additional suspicious findings.

Strong recommendation

2. Contrast studies (contrast enhanced mammography/contrast MRI):

In women with dense breasts, contrast mammography (CEM) or contrast MRI are recommended for proper staging and to exclude multicentricity/bilaterality.

Conditional recommendation

3. Image guided core biopsy:

Core biopsy should be done for assessment and histological evaluation of suspicious palpable breast abnormalities allowing for tumor receptor status. If a suspicious finding seen by mammography of DBT correlates with the palpable abnormality, biopsy is warranted even with a negative ultrasound.  If the lesion is detected by ultrasound, ultrasound-guided biopsy is the preferred approach as it is and more tolerated by the patient as it avoids breast compression and may allow biopsy for difficult to reach locations by stereotactic biopsy. A radio-opaque clip is placed and a  post-biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

Strong recommendation

4. Image guided fine needle aspiration:

Fine needle aspiration biopsy (FNAB) can be done for the assessment and histological evaluation of suspicious palpable breast abnormalities allowing for faster pathology results but with no difference in therapy timing. A radio-opaque clip is placed and a  post aspiration biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

Conditional recommendation

Variant 3: Diagnostic mammography, DBT, and US findings are probably benign (BI-RADS 3). Next imaging study.

1. Mammography:

Breast masses with mammographic features of BIRADS III morphology should undergo 6-, 12- and 24-month surveillance provided that the benign feature of the mass is persistent and there is no upgraded to BIRADS IV or V. Following a 24-month stabilization, the patient will be categorized as definitively benign BIRADS II and resume her normal screening.

Strong recommendation

2.  Ultrasound breast:

Breast masses with ultrasound features of BIRADS III morphology should undergo 6-, 12- and 24-month surveillance provided that the benign feature of the mass is persistent and there is no upgraded to BIRADS IV or V. Following a 24-month stabilization, the patient will resume her normal screening. If the mass reduces in size or disappear during the 24-month surveillance, it can be downgraded to BIRADS II

Strong recommendation

3. Image guided core biopsy:

Core biopsy is recommended if the mass is newly developed or has shown a 20%  increase in volume or single diameter size. If the lesion is detected by ultrasound, ultrasound-guided biopsy is the preferred approach as it is and more tolerated by the patient as it avoids breast compression and may allow biopsy for difficult to reach locations by stereotactic biopsy. A radio-opaque clip is placed and a  post-biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

Strong recommendation

4. Image guided fine needle aspiration:

Fine needle aspiration biopsy (FNAB) can be done if the mass is newly developed or has shown a 20%  increase in volume or single diameter size allowing for faster pathology results but with no difference in therapy timing. A radio-opaque clip is placed and a  post aspiration biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

Conditional recommendation

Variant 4: Mammography findings are benign (BI-RADS 2) at the site of palpable mass. Next imaging study.

1. Ultrasound breast:

When the mammogram shows a benign finding, ultrasound is not necessary considering that there is a certain correlation between the mammographic finding and the clinically palpable abnormality. 

If the correlation is uncertain, a targeted ultrasound examination is recommended.

Strong recommendation

2. Image guided core biopsy:

If a suspicious finding is detected by ultrasound, biopsy is recommended. A suspicious clinical examination should warrant biopsy irrespective of the imaging findings.

Strong recommendation

Variant 5: Mammography findings are negative (BI-RADS 1). Next imaging study.

1. Ultrasound breast:

Ultrasound breast should be done in women with a palpable abnormality and a negative mammogram.

Strong recommendation

2. Image guided core biopsy:

If a suspicious finding is detected by ultrasound, biopsy is recommended, A suspicious clinical examination should warrant biopsy irrespective of the imaging findings.

Strong recommendation

 

ADULT FEMALE,  30 YEARS OF AGE OR YOUNGER, PALPABLE BREAST MASS:

Variant 1: Initial imaging.

1. Ultrasound breast:

Ultrasound is the initial imaging modality of choice preferably targeted to the palpable abnormality.

      Strong recommendation

Variant 2: US findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study.

1. Mammography diagnostic:

Mammography is indicated if the suspicious ultrasound finding correlates with the clinically palpable abnormality.

       Strong recommendation

2. Digital breast tomosynthesis diagnostic:

DBT is indicated if the suspicious ultrasound finding correlates with the clinically palpable abnormality. DBT demonstrates the true extent of the lesion and exclude contralateral abnormalities particularly in young women with dense breasts.

       Strong recommendation

3. Contrast studies (contrast mammography/contrast MRI):

In women with dense breasts, contrast mammography (CEM) or contrast MRI should be recommended for proper staging and to exclude multicentricity/bilaterality.

Conditional recommendation

4. Image guided core biopsy:

Core biopsy should be done for assessment and histological evaluation of suspicious palpable breast abnormalities allowing for tumor receptor status. If a suspicious finding seen by mammography of DBT correlates with the palpable abnormality, biopsy is warranted even with a negative ultrasound.  If the lesion is detected by ultrasound, ultrasound-guided biopsy is the preferred approach as it is and more tolerated by the patient as it avoids breast compression and may allow biopsy for difficult to reach locations by stereotactic biopsy. A radio-opaque clip is placed and a  post-biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

      Strong recommendation

5. Image guided fine needle aspiration:

Fine needle aspiration biopsy (FNAB) can be done for the assessment and histological evaluation of suspicious palpable breast abnormalities allowing for faster pathology results but with no difference in therapy timing. A radio-opaque clip is placed and a  post aspiration biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

    Conditional recommendation

Variant 3: US findings probably benign (BI-RADS 3). Next imaging study.

1. Ultrasound breast:

Breast masses with ultrasound features of BIRADS III morphology should undergo 6-, 12- and 24-month surveillance provided that the benign feature of the mass is persistent and there is no upgraded to BIRADS IV or V. If the mass reduces in size or disappear during the 24-month surveillance, it can be downgraded to BIRADS II

       Strong recommendation

2. Image guided core biopsy:

Core biopsy is recommended if the mass is newly developed or has shown a 20%  increase in volume or single diameter size. If the lesion is detected by ultrasound, ultrasound-guided biopsy is the preferred approach as it is and more tolerated by the patient as it avoids breast compression and may allow biopsy for difficult to reach locations by stereotactic biopsy. A radio-opaque clip is placed and a  post-biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

      Strong recommendation

3. Image guided fine needle aspiration:

Fine needle aspiration biopsy (FNAB) can be done if the mass is newly developed or has shown a 20%  increase in volume or single diameter size allowing for faster pathology results but with no difference in therapy timing. A radio-opaque clip is placed and a  post aspiration biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

      Conditional recommendation

Variant 4: US findings benign (BI-RADS 2). Next imaging study.

              No further imaging required.

              Strong recommendation

Variant 5: US findings negative (BI-RADS 1). Next imaging study.

            No further imaging required.

            Strong recommendation

 

ADULT FEMALE, 30 to 39 YEARS OF AGE, PALPABLE BREAST MASS.

 Same guidelines as adult female 40 years or older.

Strong recommendation