From the Guidelines
For a patient with bilateral breast ultrasound findings of hypoechoic nodules classified as BI-RADS 0 with distinct margins and likely benign characteristics, the next step should be additional imaging and possibly biopsy for definitive diagnosis. The patient should undergo a diagnostic mammogram if not already performed, as this complementary imaging can provide additional information about the nodules, as suggested by the NCCN guidelines 1. Following this, a repeat targeted ultrasound may be necessary to further characterize the lesions. Since BI-RADS 0 indicates that assessment is incomplete, the radiologist needs more information before making a final category assignment, as outlined in the NCCN guidelines for breast cancer screening and diagnosis 1. If after additional imaging the nodules remain suspicious, a core needle biopsy should be performed for tissue diagnosis, in line with recommendations for BI-RADS categories 4 and 5 1. For nodules that appear definitively benign after complete assessment, short-interval follow-up imaging in 6 months may be recommended instead, as per the guidelines for follow-up evaluation of ultrasound imaging findings 1. The distinct margins noted on the initial ultrasound are generally a reassuring feature suggesting benign pathology, but cannot alone rule out malignancy. The patient should be advised that BI-RADS 0 is not a final assessment but rather an indication that the diagnostic workup is still in progress. Key considerations in the management of these patients include the clinical suspicion of malignancy, the patient's age, and the presence of any high-risk factors, as these factors influence the choice of imaging modalities and the need for biopsy, as discussed in the guidelines for asymmetric thickening or nodularity 1. Ultimately, the goal is to determine the nature of the hypoechoic nodules and to provide appropriate management to minimize morbidity, mortality, and to improve quality of life.
From the Research
Next Steps for Patient with Bilateral Breast Ultrasound Findings
The patient's bilateral breast ultrasound findings indicate hypoechoic nodules in the right breast, classified as BI-RADS 0, with distinct margins, likely of benign characteristic. The following steps can be considered:
- Comparison with previous images to assess any changes in the nodules over time 2, 3
- Correlation with mammogram results to confirm the findings and rule out any malignancy 2, 4
- Biopsy of any palpable nodule to obtain a definitive diagnosis 2, 4, 5, 6
- Consideration of core needle biopsy for non-palpable lesions, as it provides accurate and optimal diagnostic information 4, 5
- For BI-RADS 5 lesions, surgical excision with sentinel node biopsy may be considered as the first diagnostic and therapeutic procedure 6
Considerations for BI-RADS Classification
The BI-RADS classification system is a reliable method for assessing and estimating the risk of malignancy in breast lesions 3. The classification of the patient's nodules as BI-RADS 0 indicates that the study is incomplete, and additional imaging or biopsy is needed to make a definitive diagnosis.
- BI-RADS 3 lesions have a high negative predictive value for cancer, and surgery can be avoided in cases with a clear radiological and pathological benign diagnosis 4
- BI-RADS 4 and 5 lesions have a higher risk of malignancy, and biopsy or surgical excision is recommended to obtain a definitive diagnosis 2, 3, 6
Diagnostic Accuracy of Biopsy and Surgical Excision
The diagnostic accuracy of biopsy and surgical excision is high, with core needle biopsy providing accurate and optimal diagnostic information 4, 5. Surgical excision is imperative for all BI-RADS 5 lesions, irrespective of biopsy results 6.