Management of Abnormal Mammogram Results
The next step in the workup of an abnormal mammogram is to perform a diagnostic mammogram with or without ultrasound, comparing to prior films if available, followed by appropriate management based on the BI-RADS category. 1, 2
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 1, 3
- For BI-RADS 1-2 (negative or benign), return to routine screening mammography in 1 year 2, 3
- For BI-RADS 3 (probably benign), diagnostic mammograms at 6 months, then every 6-12 months for 1-2 years are recommended 1, 3
- 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 1, 3
Diagnostic Workup Considerations
- Ultrasound is highly effective in characterizing mammographic abnormalities and can detect 93-100% of cancers that are occult on mammography 1, 3
- When both mammography and ultrasound are negative or benign in the evaluation of a palpable breast mass, the negative predictive value is very high, more than 97% 3
- Core needle biopsy is preferred over fine-needle aspiration for tissue diagnosis, as it provides superior sensitivity, specificity, and correct histological grading 1, 4
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 1, 3
- For women 30 years and older, both diagnostic mammogram and ultrasound evaluation are recommended 2, 3
Important Clinical Considerations
- Geographic correlation between any palpable area and imaging findings is essential; lack of correlation requires further evaluation 2, 3
- When needle biopsy is performed, concordance between the pathology report and imaging finding must be obtained 1, 3
- A suspicious physical examination should prompt biopsy regardless of the imaging findings 3, 5
- For benign lesions concordant with imaging, physical examination with or without ultrasound or mammogram every 6-12 months for 1-2 years to assess stability is recommended 4, 3
Common Pitfalls to Avoid
- Do not assume a palpable mass is benign based solely on negative mammography; ultrasound should be performed to further evaluate 3, 5
- Avoid relying on a single imaging modality, as mammography and ultrasound provide complementary information 2, 6
- Do not delay diagnostic evaluation when additional imaging is recommended 2, 7
- Never discount an abnormal clinical breast examination because of a negative mammogram or other imaging examination 1, 6