What are the next steps for a 43-year-old female with a BI-RADS 0 classification in the right breast and BI-RADS 2 classification in the left breast after a 3D tomography screening mammogram?

Management of BI-RADS 0 and BI-RADS 2 Findings in Mammography

For a 43-year-old female with a BI-RADS 0 classification in the right breast and BI-RADS 2 classification in the left breast, the next step should be to proceed with the recommended spot tomographic imaging and ultrasound evaluation of the right breast, while continuing routine annual screening for the left breast. 1, 2

Understanding the BI-RADS Classifications

• BI-RADS 0 (Incomplete) indicates that additional imaging evaluation is needed to complete the assessment of the finding in the right breast 1
• BI-RADS 2 (Benign) indicates a negative mammogram with benign findings in the left breast that requires only routine screening 1
• The overall management approach is determined by the most worrisome finding, which in this case is the BI-RADS 0 classification in the right breast 1

Management Algorithm for Right Breast (BI-RADS 0)

1. Diagnostic Workup:

   • Perform spot compression views with tomography in the MLO projection as recommended in the report 2
   • Follow with ultrasound evaluation to characterize the small asymmetry noted in the upper breast, middle third 2

2. Subsequent Management Based on Diagnostic Imaging Results:

   • If the finding resolves or is clearly benign on additional imaging → BI-RADS 1 or 2 → return to annual screening 1
   • If the finding appears probably benign → BI-RADS 3 → short-interval follow-up at 6 months, then every 6-12 months for 1-2 years 2
   • If the finding appears suspicious → BI-RADS 4 → tissue diagnosis with core needle biopsy 2
   • If the finding is highly suggestive of malignancy → BI-RADS 5 → immediate biopsy 1

Management for Left Breast (BI-RADS 2)

• Continue with routine annual screening mammography 1
• No additional imaging or intervention is needed for the left breast at this time 1

Importance of Complete Diagnostic Evaluation

• Ultrasound provides complementary information to mammography and can detect 93-100% of cancers that may be occult on mammography 2
• The combined use of mammography and ultrasound provides a very high negative predictive value (>97%) when both are negative or benign 2
• Diagnostic evaluation should not be delayed when additional imaging is recommended 2

Common Pitfalls to Avoid

• Relying solely on a single imaging modality may miss important findings, as mammography and ultrasound provide complementary information 2
• Assuming a finding is benign based solely on its shape without complete characterization 2
• Delaying diagnostic evaluation when additional imaging is recommended 2
• Studies have shown high inter-observer variability in mammographic interpretation, highlighting the importance of following standardized protocols for additional imaging 3

Special Considerations

• Higher rates of BI-RADS 0 findings have been observed in younger women and those with a history of benign biopsy 4
• For women with breast implants (as in this case), careful evaluation is needed as implants can obscure breast tissue, making assessment more challenging 2
• Concordance between pathology and imaging findings is essential if biopsy is performed; discordance requires further investigation 2