What is the next imaging step after a bilateral digital screening mammogram recommends further imaging?

Next Imaging Step After Bilateral Digital Screening Mammogram Recommending Further Imaging

For a bilateral digital screening mammogram with BI-RADS category 0 (additional imaging required), the next step should be a diagnostic mammogram with or without ultrasound. 1

Diagnostic Workup Based on BI-RADS Assessment

For BI-RADS Category 0 (Additional Imaging Required):

• The diagnostic workup includes comparison with prior films and/or diagnostic mammogram with or without ultrasound scan 1
• This approach allows for more detailed evaluation of the area of concern identified on the screening mammogram 1

Ultrasound as a Complementary Tool:

• Ultrasound is particularly helpful in characterizing a suspicious mammographic finding 1
• It may identify additional lesions not evident on mammography or digital breast tomosynthesis 1
• Breast ultrasound should be performed using a high-resolution, real-time linear-array scanner with an adjustable focal zone and a transducer with a minimum center frequency of 10 MHz 1

Benefits of Adding Ultrasound to Diagnostic Evaluation:

• If a sonographic correlate is identified, biopsy can be performed under ultrasound guidance rather than stereotactic guidance, avoiding radiation exposure 1
• Ultrasound-guided core biopsy is usually better tolerated because it doesn't require breast compression 1
• Allows evaluation of the axilla and biopsy of suspicious lymph nodes if identified 1
• Particularly valuable for dense breast tissue, where mammography alone may miss lesions 2, 3

Management Based on Diagnostic Imaging Results

If Diagnostic Imaging Results in BI-RADS 1-3:

• For BI-RADS 1-2 (negative or benign): Return to routine screening mammography in 1 year 1
• For BI-RADS 3 (probably benign): Follow-up with diagnostic mammograms at 6 months, then every 6-12 months for 1-2 years 1
  • At first 6-month follow-up, a unilateral mammogram of the index breast is performed 1
  • The 12-month study would be bilateral in women aged 40 years and older 1

If Diagnostic Imaging Results in BI-RADS 4-5:

• Tissue diagnosis is necessary using core needle biopsy (preferred) or needle localization excisional biopsy with specimen radiograph 1
• When needle biopsy is performed, concordance between the pathology report and imaging finding must be obtained 1
• If pathology and imaging are discordant, breast imaging should be repeated and additional tissue sampled or excised 1

Special Considerations

Age-Related Approach:

• For women under 30 years of age, ultrasound evaluation is typically the first approach, followed by consideration of diagnostic mammography 1
• For women 30 years and older, both diagnostic mammogram and ultrasound evaluation are recommended 1

Dense Breast Tissue:

• Supplemental ultrasound after negative mammographic screening permits diagnosis of primarily invasive carcinomas in 0.32% of women with dense breasts 3
• Most detected cancers in supplemental screening occur in mammographically dense breast ACR types 3 and 4 3

Common Pitfalls to Avoid

• Do not rely solely on ultrasound for screening purposes without mammography 4
• Avoid delaying diagnostic evaluation when additional imaging is recommended 1
• Remember that concordance between pathology and imaging findings is essential; discordance requires further investigation 1
• Be aware that supplemental ultrasound increases cancer detection but also increases false positives, biopsy rates, and follow-up exams 4