What are the next steps after an abnormal finding on a breast exam or imaging?

Management of Abnormal Breast Findings

For abnormal findings on breast exam or imaging, proceed to diagnostic evaluation with appropriate imaging and biopsy based on the specific finding, with ultrasound as the initial imaging modality for palpable masses regardless of age. 1

Initial Assessment Based on Presentation

Palpable Abnormalities

• Ultrasound is the recommended first imaging modality for palpable breast masses regardless of age 1

  • Particularly appropriate for younger women due to higher sensitivity in dense breast tissue (95.7% vs 60.9% for mammography in women under 30) 1
  • Helps distinguish simple cysts from solid masses 2

• Next steps based on ultrasound findings:

  • Simple cyst: No further workup needed 1
  • Solid mass with benign features: Short-interval follow-up if mammography and clinical examination also suggest benign etiology 1
  • Indeterminate findings: Proceed to diagnostic mammography/tomosynthesis 1
  • Suspicious findings: Proceed to diagnostic mammography (rated 8/9 by ACR) AND image-guided core needle biopsy (rated 9/9) 1

Abnormal Mammographic Findings

• Management based on BI-RADS category: 2
  • "Highly suggestive of malignancy" or "Suspicious abnormality": Proceed to core-needle biopsy or needle localization with surgical biopsy
  • "Need additional imaging evaluation": Proceed to diagnostic mammography or ultrasonography to determine if biopsy is needed
  • "Probably benign finding": Follow-up mammography in 6 months

Diagnostic Procedures

Biopsy Approach

• Core needle biopsy (CNB) is preferred over fine needle aspiration (FNA) 1

  • Ensure concordance between pathology report and imaging findings
  • Imaging should precede biopsy to avoid alteration of imaging findings 1

• For impalpable lesions:

  • Radiologically guided core biopsy is recommended 3
  • Histological diagnosis should be compared with diagnostic hypotheses from imaging 3

Important Caveats

• Beware of false negatives: A common error is to assume a palpable mass not visible on mammogram is not cancerous 4
• Frozen sections are not indicated for isolated clusters of microcalcification or tumors <10mm 3
• MRI has limited utility: Not routinely recommended for palpable abnormalities after negative mammography and ultrasound (low yield for malignancy) 5
  • Consider MRI only in specific situations: BRCA mutations, breast implants, lobular cancers, inconclusive conventional imaging, or suspicion of multifocality 1

Follow-Up and Surveillance

• For benign concordant findings: Follow-up imaging at 6-12 months 1
• For atypical findings: Surgical excision is recommended 1
• For malignant findings: Proceed to definitive surgical management 1

Pathological Assessment

The standard histological report should include: 3

• Size of malignant lesion(s) in mm
• Histological type and grade
• Percentage of any ductal carcinoma in situ
• Presence of peritumoral vascular invasion
• Status of surgical margins

Special Considerations

• Diagnosis of ductal carcinoma in situ, lobular carcinoma in situ, and atypical hyperplasia from needle biopsy should always be confirmed with surgical excision 3

• For higher-risk disease: Additional staging workup should include complete blood count, liver and renal function tests, alkaline phosphatase, and calcium 1

• Assessment for distant metastases is only recommended in stage IIb and higher disease 1

The diagnostic approach should be systematic and multidisciplinary, with findings discussed by a team of specialists to ensure accurate diagnosis and appropriate management 3.