What is the recommended approach for evaluating a breast mass?

From the Guidelines

The recommended approach for evaluating a breast mass begins with a thorough clinical breast examination, followed by appropriate imaging based on the patient's age and risk factors, with ultrasound as the initial imaging modality for women under 30 and diagnostic mammography with ultrasound for women 30 and older.

Key Considerations

• For women under 30, ultrasound is typically the first imaging modality, as recommended by 1 and 1.
• For women 30 and older, diagnostic mammography with ultrasound is the preferred initial evaluation, as stated in 1 and 1.
• If imaging reveals suspicious features (BI-RADS 4 or 5), a core needle biopsy should be performed for definitive diagnosis, as suggested by 1 and 1.
• Fine needle aspiration may be used for simple cysts but is generally less preferred than core biopsy, according to 1.
• For palpable masses with benign imaging features (BI-RADS 1-3), clinical follow-up in 3-6 months is appropriate to ensure stability, as recommended by 1.

Additional Recommendations

• Women with high genetic risk or dense breast tissue may benefit from additional screening with MRI, as mentioned in the example answer.
• Prompt evaluation is essential since early detection of malignancy significantly improves treatment outcomes and survival rates, as emphasized in 1.
• The decision to perform surgical excisional versus percutaneous biopsy should involve the patient and her health care provider, as stated in 1.
• Image-guided core-needle biopsy has become the procedure of choice for most image-detected breast lesions requiring tissue diagnosis, due to its advantages over surgical biopsy, including less scarring, fewer complications, faster recovery, less cost, and similar accuracy, as discussed in 1.

From the Research

Evaluation Approach

The recommended approach for evaluating a breast mass involves a combination of clinical assessment, imaging studies, and biopsy when necessary.

• A detailed clinical history and physical examination are essential in the initial evaluation of a breast mass 2.
• Imaging studies, such as mammography and ultrasonography, play a crucial role in the evaluation of a breast mass. Diagnostic mammography is usually the imaging study of choice, but ultrasonography is more sensitive in women younger than 30 years 2.
• The Breast Imaging Reporting and Data System (BI-RADS) is used to categorize mammography results, with likelihood ratios ranging from 0.1 for a "negative or benign finding" to 2200 for a "highly suggestive of malignancy" 3.

Biopsy Indications

Biopsy is indicated for suspicious masses, including those with a mammogram considered malignant or suspicious, aspiration cytologic findings reported as malignant or suspicious, and a persisting, dominant mass, even if clinically benign 4.

• Fine-needle aspiration biopsy and core-needle biopsy are options for biopsy, with fine-needle aspiration biopsy allowing characterization of a solid mass 3, 2.
• Excisional biopsy may be necessary for definitive diagnosis in some cases.

Special Considerations

• Women with a family history of breast cancer or other risk factors may require more thorough evaluation and follow-up 4.
• The evaluation of a breast mass should be performed expeditiously, and the results communicated promptly to the patient 5.
• Regardless of the age of the woman, a clinically suspicious mass must be evaluated even if findings on a mammogram are normal 5.