What is the next best step (NBS) for a 40-year-old female with a self-palpable mass in the left breast's upper outer quadrant, where the mass is not palpable in the other breast?

From the Guidelines

For a 40-year-old female with a self-palpable mass in the left breast upper outer quadrant and no palpable mass in the other breast, the next best step (NBS) is to perform a diagnostic mammography in both breasts, as it is the initial imaging test of choice for women 40 years and older with breast symptoms, with a rating of 9, indicating it is usually appropriate 1.

Rationale

The American College of Radiology (ACR) appropriateness criteria for palpable breast masses recommend mammography as the first-line imaging modality for women over 40 years old, due to its ability to detect calcifications and architectural distortions that may not be visible on ultrasound 1.

Key Considerations

• Mammography provides a comprehensive evaluation of both breasts, which is essential for identifying occult lesions that may be present in either breast.
• Bilateral imaging is standard practice, even when symptoms are unilateral, as it establishes a baseline for future comparison and can identify clinically occult lesions in the contralateral breast.
• After mammography, targeted ultrasound may be used as a complementary test to further characterize the palpable mass, especially to distinguish between solid and cystic lesions.

Supporting Evidence

The ACR appropriateness criteria for palpable breast masses, as outlined in the study by 1, provide a rating scale for various radiologic procedures, with mammography receiving a rating of 9, indicating it is usually appropriate.

Clinical Implications

In clinical practice, prioritizing mammography as the initial imaging test for women over 40 years old with breast symptoms can help ensure timely and accurate diagnosis, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Next Best Step for a 40-year-old Female with a Self-Palpable Mass

• The patient is 40 years old, which places her in the age group where diagnostic mammography and tomosynthesis are the appropriate initial imaging modalities for a palpable breast mass 2.
• According to the American College of Radiology Appropriateness Criteria, ultrasound may also be appropriate if the patient had a negative mammogram within 6 months of presentation or immediately after mammography findings are suspicious or highly suggestive of malignancy 2.
• A thorough clinical breast examination, imaging, and tissue sampling are needed for a definitive diagnosis of a palpable breast mass 3.
• Fine-needle aspiration can be used to differentiate solid and cystic masses, but core-needle biopsy may be necessary for a histologic diagnosis and to guide treatment 3.
• The evaluation of a palpable breast mass depends largely on the patient's age and examination characteristics, as well as the physician's experience in performing fine-needle aspiration 3.
• Ultrasound can be useful in characterizing palpable masses and detecting cancer in women with negative mammograms, and may be considered as an initial imaging modality, especially in younger women 4.
• Given the patient's age and the presence of a self-palpable mass in the left breast's upper outer quadrant, diagnostic mammography and tomosynthesis are likely the next best step, possibly followed by ultrasound if the mammography findings are suspicious or highly suggestive of malignancy 2.