What tests should be run on a patient presenting with mastalgia (breast pain) and breast nodules?

From the Guidelines

For a patient presenting with mastalgia and breast nodules, the initial diagnostic approach should include a thorough clinical breast examination, followed by imaging studies, with mammography recommended for women over 30 and ultrasound preferred for younger patients or as a complementary test to mammography. The choice of imaging modality depends on the patient's age and the nature of the breast pain and nodules. According to the American College of Radiology Appropriateness Criteria 1, for women with clinically significant breast pain (focal and noncyclical), imaging studies are appropriate, with ultrasound recommended for women under 30 and mammography, including digital breast tomosynthesis (DBT), and ultrasound equivalent alternatives for women between 30 and 39 years old. For women 40 years and older, mammography and DBT are appropriate and complementary to ultrasound.

Key Considerations

• A thorough clinical breast examination is essential to identify any palpable masses, asymmetric thickening, nipple discharge, or skin changes.
• Imaging studies should be guided by the patient's age and the nature of the breast pain and nodules.
• Mammography is recommended for women over 30, while ultrasound is preferred for younger patients or as a complementary test to mammography.
• If the nodule appears suspicious on imaging, a fine needle aspiration (FNA) or core needle biopsy should be performed to obtain tissue for pathological examination, as recommended by the NCCN Clinical Practice Guidelines in Oncology 1.
• Additional tests may include complete blood count, thyroid function tests, and prolactin levels if hormonal causes are suspected.

Diagnostic Approach

• For patients with cyclical breast pain, a pain diary tracking symptoms in relation to menstrual cycles can be helpful.
• MRI might be considered in specific cases where mammography and ultrasound results are inconclusive or for high-risk patients, although its role is limited in the evaluation of palpable breast masses, as stated in the ACR Appropriateness Criteria 1.
• The diagnostic evaluation should be expedited for patients with concerning features such as a hard, fixed mass, skin changes, nipple discharge, or family history of breast cancer.

From the Research

Diagnostic Approach for Mastalgia and Breast Nodules

The diagnostic approach for patients presenting with mastalgia (breast pain) and breast nodules involves a thorough history and physical examination to determine the need for diagnostic imaging 2, 3, 4, 5, 6.

• A detailed clinical history and physical examination are essential to identify predisposing factors and to classify the breast pain as cyclical or non-cyclical 5, 6.
• For women presenting with a breast mass, imaging and further assessment are required to exclude cancer 5.
• The choice of imaging modality depends on the patient's age and symptoms:
  • Women younger than 30 years: ultrasound (US) is the first-line investigation 4, 5.
  • Women between 30 and 40 years: US is the modality of choice, while full-field digital mammography (FFDM) or digital breast tomosynthesis (DBT) may also be performed if needed 4.
  • Women over 40 years: both FFDM or DBT and US are usually required 4.
• For patients with focal breast pain, targeted ultrasonography localized to discrete areas of the breast can be used alone in women younger than 30 years, and as an adjunct to mammography in women 30 years and older 5.
• If a suspicious mass is detected on physical examination, mammography, or ultrasonography, a biopsy should be performed, usually a core needle biopsy with imaging guidance 5.
• Advanced techniques such as breast magnetic resonance imaging (MRI) or contrast-enhanced mammography are not indicated in the initial diagnostic setting and are reserved for cases of established malignancy or rare cases of equivocal findings 4.