What is the appropriate workup for a breast lump?

Appropriate Workup for a Breast Lump

The appropriate workup for a breast lump requires thorough imaging evaluation before biopsy, with the initial imaging modality determined by patient age: ultrasound for women under 30, either ultrasound or mammography/digital breast tomosynthesis (DBT) for women 30-39, and diagnostic mammography/DBT for women 40 and older. 1

Age-Based Initial Imaging Approach

Women under 30 years:

• Ultrasound is the initial imaging modality of choice due to lower breast cancer risk, dense breast tissue, and concerns about radiation exposure 1
• If ultrasound reveals suspicious findings, diagnostic mammography should follow to evaluate for additional lesions or calcifications 1
• Mammography is not recommended as the initial imaging test in this age group 1

Women 30-39 years:

• Either ultrasound or diagnostic mammography/DBT can be used as the initial imaging modality 1
• Ultrasound may have higher sensitivity than mammography in this age group (95.7% vs 60.9%) 1
• If a suspicious mass is identified on ultrasound, bilateral mammography is recommended 1

Women 40 years and older:

• Diagnostic mammography or DBT is the initial imaging modality of choice 1
• Sensitivity of mammography alone in evaluating palpable breast abnormalities is 86-91% 1
• If mammography is negative or identifies a finding not clearly benign, targeted ultrasound should follow 1

Imaging Correlation and Further Evaluation

• Correlation between imaging and the palpable area of concern is essential 1
• The negative predictive value of combined mammography with ultrasound for palpable masses ranges from 97.4% to 100% 1
• If a clearly benign correlate is identified on mammography (oil cyst, hamartoma, degenerating fibroadenoma, lipoma, benign lymph node), clinical follow-up is appropriate 1
• For indeterminate or suspicious findings, tissue sampling is required 1

Tissue Sampling

• Core needle biopsy is superior to fine-needle aspiration biopsy (FNAB) in terms of sensitivity, specificity, and correct histological grading 1
• Image-guided biopsy is preferred over palpation-guided biopsy, even for palpable masses 1
• Ultrasound-guided biopsy is preferred when a lesion is visible on both ultrasound and mammography due to patient comfort, real-time visualization, and absence of radiation 1

Important Caveats

• Negative imaging should never overrule a highly suspicious finding on physical examination 1
• Any highly suspicious breast mass detected by palpation should undergo biopsy regardless of imaging findings 1
• Imaging should occur before biopsy, as biopsy-related changes may confuse or limit image interpretation 1
• Only 56.9% of women with breast lumps and normal mammograms receive adequate evaluation, highlighting the importance of thorough workup 2
• Triple assessment (clinical examination, imaging, and tissue sampling) has higher accuracy than any single modality alone 3

Special Considerations

• For inflammatory breast masses, ultrasound is particularly valuable as it can immediately determine if the mass is a fluid collection, solid inflammatory mass, or complex lesion 4
• Digital breast tomosynthesis (DBT) may improve lesion characterization in non-calcified lesions compared to conventional mammography 1
• There is no role for MRI, PET, or molecular breast imaging in the initial evaluation of a palpable breast mass 1