Management of Abnormal Mammogram Results
After an abnormal mammogram, patients should undergo a complete diagnostic workup including additional mammographic views with spot compression, tomography, and ultrasound evaluation to characterize the finding before proceeding to tissue sampling if necessary. 1
Initial Assessment Based on BI-RADS Category
- For BI-RADS 0 (needs additional imaging), a diagnostic mammogram with or without ultrasound should be performed, with comparison to prior films if available 2
- For BI-RADS 3 (probably benign), diagnostic mammograms at 6 months, then every 6-12 months for 1-2 years are recommended 2
- For BI-RADS 4-5 (suspicious or highly suggestive of malignancy), tissue diagnosis is necessary using core needle biopsy (preferred) or needle localization excisional biopsy with specimen radiography 2
- For BI-RADS 1-2 (negative or benign), return to routine screening mammography in 1 year 1
Diagnostic Workup Process
- Ultrasound is highly effective in characterizing mammographic abnormalities and can detect 93-100% of cancers that are occult on mammography 1
- The combined use of mammography and ultrasound provides a very high negative predictive value (>97%) when both are negative or benign 1
- When a suspicious finding is identified, tissue sampling should be pursued rather than short-interval follow-up 2
- Geographic correlation between palpable areas and imaging findings is essential; lack of correlation requires further evaluation 1
Age-Specific Considerations
- For women under 30 years of age with abnormal findings, ultrasound is the preferred initial evaluation, followed by consideration of diagnostic mammography if needed 2
- For women 30 years and older, both diagnostic mammogram and ultrasound evaluation are recommended 2
- For women with palpable masses younger than 30 years, observation for 1-2 menstrual cycles is an option in cases with low clinical suspicion 2
Tissue Sampling
- Core needle biopsy is preferred over fine-needle aspiration for tissue diagnosis, as it is superior in terms of sensitivity, specificity, and correct histological grading 2
- When needle biopsy is performed, concordance between the pathology report and imaging finding must be obtained 2
- If pathology and imaging are discordant, breast imaging should be repeated and additional tissue sampled or excised 2
- Surgical excision is recommended if pathology/image remain discordant 2
Follow-Up of Specific Findings
- For simple cysts identified on ultrasound, they are considered benign (BI-RADS 2) and can return to routine screening 1
- For solid masses with benign features on ultrasound, they are likely BI-RADS 3 requiring short-interval follow-up 1
- For women with atypical hyperplasia, LCIS, or other potentially pathologic conditions found on biopsy, surgical excision is recommended 2
- Any malignant findings with biopsy or surgical excision should be treated according to breast cancer treatment guidelines 2
Common Pitfalls to Avoid
- Do not discount an abnormal clinical breast examination because of a negative mammogram or other imaging examination 2
- Avoid relying on a single imaging modality, as mammography and ultrasound provide complementary information 1
- Do not assume a finding is benign based solely on its shape without complete characterization 1
- Diagnostic mammography does not help determine whether a palpable breast mass should be biopsied and should not affect the decision to perform a biopsy 3
- Avoid delays in follow-up, which can lead to postponement of treatment and potentially decreased survival for women with cancer 4
Factors That May Delay Diagnosis
- Being notified of results by letter or telephone rather than in person 5
- Not fully understanding the results of the index mammogram 5
- Lower socioeconomic status 5
- Lack of previous mammogram experience 4
Following these guidelines ensures timely and appropriate management of abnormal mammogram findings, optimizing early detection and treatment of breast cancer while minimizing unnecessary procedures.